Provider Demographics
NPI:1588032205
Name:MARTIN, RYAN KYLE
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:KYLE
Last Name:MARTIN
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 1:10 CANALVIEW MALL STE C
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069-1769
Mailing Address - Country:US
Mailing Address - Phone:315-593-8786
Mailing Address - Fax:315-598-5538
Practice Address - Street 1:10 CANALVIEW MALL STE C
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-1769
Practice Address - Country:US
Practice Address - Phone:315-593-8786
Practice Address - Fax:315-598-5538
Is Sole Proprietor?:No
Enumeration Date:2015-09-11
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039120225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist