Basic Information
| Provider Information | |||||||||
| NPI: | 1891838124 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NYBERG | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | WALLACE | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11913 BAYPOINT DR | ||||||||
| Address2: | |||||||||
| City: | BURNSVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553373368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528907682 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3915 GOLDEN VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635880811 | ||||||||
| FaxNumber: | 7635200355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 225100000X | 7395 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.