Provider Demographics
NPI:1679171342
Name:WILSON, RYAN ZACHARY (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:ZACHARY
Last Name:WILSON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 YORK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1925
Mailing Address - Country:US
Mailing Address - Phone:630-575-1980
Mailing Address - Fax:
Practice Address - Street 1:2900 W PETERSON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-3818
Practice Address - Country:US
Practice Address - Phone:773-596-5484
Practice Address - Fax:773-862-8578
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT130542251X0800X
NJ40QA019612002251X0800X
NY0465072251X0800X
IL070-026470225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY046507OtherNY PHYSICAL THERAPY LICENSE
NJ40QA01961200OtherNJ PT LICENSE