Provider Demographics
NPI:1437938131
Name:SULLIVAN, RYAN THOMAS (PTA)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:THOMAS
Last Name:SULLIVAN
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 1:140 BAY ST APT 7
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-6156
Mailing Address - Country:US
Mailing Address - Phone:304-695-6707
Mailing Address - Fax:
Practice Address - Street 1:140 BAY ST APT 7
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-6156
Practice Address - Country:US
Practice Address - Phone:304-695-6707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-22
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47991225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant