Provider Demographics
NPI:1568505790
Name:MADISON, RYAN EDWARD (PT, MS)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:EDWARD
Last Name:MADISON
Suffix:
Gender:M
Credentials:PT, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5032 N VASSAULT ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98407-1333
Mailing Address - Country:US
Mailing Address - Phone:425-422-2633
Mailing Address - Fax:
Practice Address - Street 1:5032 N VASSAULT ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98407-1333
Practice Address - Country:US
Practice Address - Phone:425-422-2633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00008956225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA163564OtherLABOR AND INDUSTRY
WA8337016Medicaid