Provider Demographics
NPI:1659811503
Name:RYAN, THOMAS (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:RYAN
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 SCOTT BLVD.
Mailing Address - Street 2:STE. 1
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52240
Mailing Address - Country:US
Mailing Address - Phone:319-354-2429
Mailing Address - Fax:319-354-6100
Practice Address - Street 1:540 E. JEFFERSON STREET
Practice Address - Street 2:STE. 302
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52245
Practice Address - Country:US
Practice Address - Phone:319-339-3611
Practice Address - Fax:319-339-3878
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-26
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00689225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA06-065463Medicaid