Provider Demographics
NPI:1629501606
Name:TATE, RYAN (PTA)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:TATE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1539 MCHENRY AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4528
Mailing Address - Country:US
Mailing Address - Phone:209-578-3290
Mailing Address - Fax:209-529-8643
Practice Address - Street 1:1539 MCHENRY AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4528
Practice Address - Country:US
Practice Address - Phone:209-578-3290
Practice Address - Fax:209-529-8643
Is Sole Proprietor?:No
Enumeration Date:2017-04-06
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTA 10561225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant