Basic Information
| Provider Information | |||||||||
| NPI: | 1760046767 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOLAN | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | MARK | ||||||||
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| Credential: | LAT, ATC, OTC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 BEECH RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | SCARBOROUGH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040749105 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 46 BARRA RD STE 103 | ||||||||
| Address2: | |||||||||
| City: | BIDDEFORD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040059461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072831126 | ||||||||
| FaxNumber: | 2072943544 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2019 | ||||||||
| LastUpdateDate: | 04/24/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZX2200X | 19-0208 | ME | N | 2255A2300X | AT735 | ME | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.