Provider Demographics
NPI:1093395394
Name:SHORT, THOMAS RYAN (LPTA, LMT)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:RYAN
Last Name:SHORT
Suffix:
Gender:M
Credentials:LPTA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4060 WESTWIND DR
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-5168
Mailing Address - Country:US
Mailing Address - Phone:703-927-5395
Mailing Address - Fax:
Practice Address - Street 1:1936 OPITZ BLVD STE A
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3360
Practice Address - Country:US
Practice Address - Phone:540-841-4443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-11
Last Update Date:2021-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019011669225700000X
VA2306605845225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist