Provider Demographics
NPI:1073915666
Name:RYAN, CONNOR LEE (PT, DPT, CSCS)
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:LEE
Last Name:RYAN
Suffix:
Gender:M
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1931 E ROSS DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-9040
Mailing Address - Country:US
Mailing Address - Phone:508-864-5038
Mailing Address - Fax:
Practice Address - Street 1:3336 E CHANDLER HEIGHTS RD
Practice Address - Street 2:STE 126
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85298-4259
Practice Address - Country:US
Practice Address - Phone:480-840-6125
Practice Address - Fax:480-840-6122
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12204PT2251X0800X
NY036910-1225100000X
NJ40QA01539700225100000X
MA20731225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist