Provider Demographics
NPI:1134701543
Name:BACLIT, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BACLIT
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 1:17018 76TH AVE
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11366-1319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:575 8TH AVE FL 6
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-3158
Practice Address - Country:US
Practice Address - Phone:212-221-1544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-25
Last Update Date:2021-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012676-01225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant