Provider Demographics
NPI:1396018065
Name:JUAREZ, RYAN RON (DPT,PT, ATC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:RON
Last Name:JUAREZ
Suffix:
Gender:M
Credentials:DPT,PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 N 17TH AVE STE 7
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4283
Mailing Address - Country:US
Mailing Address - Phone:715-845-2942
Mailing Address - Fax:715-842-3416
Practice Address - Street 1:327 N 17TH AVE STE 7
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4283
Practice Address - Country:US
Practice Address - Phone:715-845-2942
Practice Address - Fax:715-842-3416
Is Sole Proprietor?:No
Enumeration Date:2012-02-10
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT38395225100000X
GAPT014515225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB243091Medicare PIN
CAW17215Medicare PIN
CACB243092Medicare PIN
CAW17215AMedicare PIN