Provider Demographics
NPI:1609521178
Name:IGGULDEN, RYAN DUANE (CLINIC DIRECTOR)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:DUANE
Last Name:IGGULDEN
Suffix:
Gender:M
Credentials:CLINIC DIRECTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 BROADWAY ST STE 101
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98663-3455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12849 NW CORNELL RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-5813
Practice Address - Country:US
Practice Address - Phone:530-208-6279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-14
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60541198225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant