Provider Demographics
NPI:1003247891
Name:GARY, RYAN SANDERS (PT, DPT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:SANDERS
Last Name:GARY
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1331 LAKE DR SE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-1674
Mailing Address - Country:US
Mailing Address - Phone:616-248-9842
Mailing Address - Fax:616-248-9848
Practice Address - Street 1:1331 LAKE DR SE
Practice Address - Street 2:SUITE 105
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-1674
Practice Address - Country:US
Practice Address - Phone:616-248-9842
Practice Address - Fax:616-248-9848
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-05
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016584225100000X
COPTL.0012446225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist