Provider Demographics
NPI:1417422635
Name:GREEN, RYAN (PTA)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 ORCHID LN
Mailing Address - Street 2:
Mailing Address - City:SLIPPERY ROCK
Mailing Address - State:PA
Mailing Address - Zip Code:16057-5229
Mailing Address - Country:US
Mailing Address - Phone:724-996-6793
Mailing Address - Fax:
Practice Address - Street 1:9108 PA-198
Practice Address - Street 2:
Practice Address - City:CONNEAUTVILLE
Practice Address - State:PA
Practice Address - Zip Code:16406
Practice Address - Country:US
Practice Address - Phone:814-587-2012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-04
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE011793208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation