Provider Demographics
NPI:1659855500
Name:EDGAR, RYAN A (PT)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:A
Last Name:EDGAR
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 1:302 W MAIN ST STE 204
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-4306
Mailing Address - Country:US
Mailing Address - Phone:860-679-0430
Mailing Address - Fax:860-679-0431
Practice Address - Street 1:61 MAPLE AVE STE 2
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:CT
Practice Address - Zip Code:06019-3058
Practice Address - Country:US
Practice Address - Phone:860-352-2463
Practice Address - Fax:860-352-8247
Is Sole Proprietor?:No
Enumeration Date:2018-09-17
Last Update Date:2022-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11929225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist