Provider Demographics
NPI:1619581360
Name:LANDRY, NICHOLAS RYAN (MS, PT, DPT)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:RYAN
Last Name:LANDRY
Suffix:
Gender:M
Credentials:MS, PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 GRAND CENTRAL AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-1079
Mailing Address - Country:US
Mailing Address - Phone:304-693-2781
Mailing Address - Fax:
Practice Address - Street 1:313 MACCORKLE AVE SW STE 100
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-1207
Practice Address - Country:US
Practice Address - Phone:304-746-3704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist