Provider Demographics
NPI:1598178063
Name:HENDRICKS, RYAN (DPT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:HENDRICKS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 E HAYDEN ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4726
Mailing Address - Country:US
Mailing Address - Phone:208-283-2748
Mailing Address - Fax:
Practice Address - Street 1:1224 E HAYDEN ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4726
Practice Address - Country:US
Practice Address - Phone:208-283-2748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-3634225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist