Provider Demographics
NPI:1689187106
Name:NIELSON, RYAN (DPT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:NIELSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S INDEPENDENCE AVE
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:VA
Mailing Address - Zip Code:24348-3972
Mailing Address - Country:US
Mailing Address - Phone:276-773-0303
Mailing Address - Fax:
Practice Address - Street 1:400 S INDEPENDENCE AVE
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:VA
Practice Address - Zip Code:24348-3972
Practice Address - Country:US
Practice Address - Phone:276-773-0303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-06
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305208961225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist