Provider Demographics
NPI:1417587676
Name:ELASSAL, RYAN EDWARD (PT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:EDWARD
Last Name:ELASSAL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16905 HALBROOKE CIR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-6864
Mailing Address - Country:US
Mailing Address - Phone:405-996-0660
Mailing Address - Fax:
Practice Address - Street 1:7919 MID AMERICA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73135-6611
Practice Address - Country:US
Practice Address - Phone:405-736-0064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-16
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5329225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist