Provider Demographics
NPI:1962975557
Name:UTTERBACK, RYAN TIMOTHY
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:TIMOTHY
Last Name:UTTERBACK
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 1:6938 LITTLETON DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46221-4838
Mailing Address - Country:US
Mailing Address - Phone:317-473-1613
Mailing Address - Fax:
Practice Address - Street 1:6938 LITTLETON DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46221-4838
Practice Address - Country:US
Practice Address - Phone:317-473-1613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-07
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer