Provider Demographics
NPI:1306364617
Name:RYDER, JOHN GAGE (MS, ATC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:GAGE
Last Name:RYDER
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 GRAND CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-1081
Mailing Address - Country:US
Mailing Address - Phone:304-295-7290
Mailing Address - Fax:304-295-5922
Practice Address - Street 1:1605 GRAND CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-1081
Practice Address - Country:US
Practice Address - Phone:304-295-7290
Practice Address - Fax:304-295-5922
Is Sole Proprietor?:No
Enumeration Date:2017-09-07
Last Update Date:2022-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20000207392255A2300X
WVPT004414225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1356766059Medicaid