Provider Demographics
NPI:1366807455
Name:NEAL, RYAN WILLIAM (MED, ATC, CSCS)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:WILLIAM
Last Name:NEAL
Suffix:
Gender:M
Credentials:MED, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2629 E ROSE GARDEN LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-4605
Mailing Address - Country:US
Mailing Address - Phone:602-734-5800
Mailing Address - Fax:
Practice Address - Street 1:2629 E ROSE GARDEN LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-4605
Practice Address - Country:US
Practice Address - Phone:602-734-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-16
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14512255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
070802004OtherBOC
7247829113OtherNSCA CSCS