Provider Demographics
NPI:1659412062
Name:WATANABE, KRISTOPHER RYAN (PT)
Entity Type:Individual
Prefix:MR
First Name:KRISTOPHER
Middle Name:RYAN
Last Name:WATANABE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 4TH ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-1124
Mailing Address - Country:US
Mailing Address - Phone:559-322-5345
Mailing Address - Fax:559-322-5041
Practice Address - Street 1:615 4TH ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-1124
Practice Address - Country:US
Practice Address - Phone:559-322-5345
Practice Address - Fax:559-322-5041
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT29007225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT29007OtherLICENSE NUMBER