Provider Demographics
NPI:1447629183
Name:JUDD, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:JUDD
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 1:27 GOLDEN DR
Mailing Address - Street 2:
Mailing Address - City:EASTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01027-2565
Mailing Address - Country:US
Mailing Address - Phone:413-320-8429
Mailing Address - Fax:
Practice Address - Street 1:27 GOLDEN DR
Practice Address - Street 2:
Practice Address - City:EASTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01027-2565
Practice Address - Country:US
Practice Address - Phone:413-320-8429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-23
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAT00425246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI2255A2300XOtherTECHNOLOGIST, ATHLETIC TRAINER