Provider Demographics
NPI:1578017943
Name:MYRICK, RYAN RUSSELL (PTA)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:RUSSELL
Last Name:MYRICK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:MR
Other - First Name:RYAN
Other - Middle Name:RUSSELL
Other - Last Name:MYRICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:8114 SANDPIPER CIR
Mailing Address - Street 2:SUITE 114
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-4934
Mailing Address - Country:US
Mailing Address - Phone:410-933-8459
Mailing Address - Fax:410-933-8712
Practice Address - Street 1:8114 SANDPIPER CIR
Practice Address - Street 2:SUITE 114
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-4934
Practice Address - Country:US
Practice Address - Phone:410-933-8459
Practice Address - Fax:410-933-8712
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49721225200000X
MDA4508225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant