Provider Demographics
NPI:1962756825
Name:DAUGHERTY, RYAN DEVIN RICHARD
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:DEVIN RICHARD
Last Name:DAUGHERTY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4404 W BONANZA RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-2127
Mailing Address - Country:US
Mailing Address - Phone:702-498-2635
Mailing Address - Fax:
Practice Address - Street 1:4404 W BONANZA RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-2127
Practice Address - Country:US
Practice Address - Phone:702-498-2635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner