Provider Demographics
NPI:1568420354
Name:WALLACE, RYAN JAMES (PT, DPT, OCS, MTC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:JAMES
Last Name:WALLACE
Suffix:
Gender:M
Credentials:PT, DPT, OCS, MTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8079 BRETON CIR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4651
Mailing Address - Country:US
Mailing Address - Phone:239-947-4184
Mailing Address - Fax:239-947-4181
Practice Address - Street 1:25241 ELEMENTARY WAY
Practice Address - Street 2:STE 200
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-7883
Practice Address - Country:US
Practice Address - Phone:239-947-4184
Practice Address - Fax:239-947-4171
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 18604225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY8999ZMedicare ID - Type UnspecifiedINDIVIDUAL PRACTIONER