Provider Demographics
NPI:1245745629
Name:BRUBAKER, RYAN MICHAEL
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:MICHAEL
Last Name:BRUBAKER
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 1:5 W 1060 N
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:UT
Mailing Address - Zip Code:84737-1913
Mailing Address - Country:US
Mailing Address - Phone:435-218-6726
Mailing Address - Fax:
Practice Address - Street 1:1952 E FORT UNION BLVD
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-6877
Practice Address - Country:US
Practice Address - Phone:801-942-3311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-07
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9421945-2402225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant