Provider Demographics
NPI:1679989578
Name:DESMARAIS, RYAN (PT)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:
Last Name:DESMARAIS
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 1:109 LAKE DAVENPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33897-9405
Mailing Address - Country:US
Mailing Address - Phone:863-256-5030
Mailing Address - Fax:
Practice Address - Street 1:109 LAKE DAVENPORT BLVD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33897-9405
Practice Address - Country:US
Practice Address - Phone:863-256-5030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-11
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT28692225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist