Provider Demographics
NPI:1477163368
Name:ELLIS, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 TUSSEYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:CENTRE HALL
Mailing Address - State:PA
Mailing Address - Zip Code:16828-9150
Mailing Address - Country:US
Mailing Address - Phone:412-608-7190
Mailing Address - Fax:
Practice Address - Street 1:69 COTTAGE RD
Practice Address - Street 2:
Practice Address - City:MIFFLIN
Practice Address - State:PA
Practice Address - Zip Code:17058-7030
Practice Address - Country:US
Practice Address - Phone:717-436-8921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology