Provider Demographics
NPI:1003327438
Name:RUYBALID, IAN SEAN (PTA)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:SEAN
Last Name:RUYBALID
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 VALLEJOS LN
Mailing Address - Street 2:LOS LUNAS SPECIAL SERVICES
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031
Mailing Address - Country:US
Mailing Address - Phone:505-866-8338
Mailing Address - Fax:
Practice Address - Street 1:343 VALLEJOS LN
Practice Address - Street 2:LOS LUNAS SPECIAL SERVICES
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031
Practice Address - Country:US
Practice Address - Phone:505-866-8338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-12
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-1416225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant