Provider Demographics
NPI:1750774154
Name:RYSDYK, MATTHEW (ATC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:RYSDYK
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 S MILTON RD
Mailing Address - Street 2:APT. #153
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-6337
Mailing Address - Country:US
Mailing Address - Phone:616-304-8100
Mailing Address - Fax:
Practice Address - Street 1:1830 S MILTON RD
Practice Address - Street 2:APT. #153
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-6337
Practice Address - Country:US
Practice Address - Phone:616-304-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-09
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI26010016022255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program