Provider Demographics
NPI:1710395934
Name:EASTRIDGE, RYAN P (PT, DPT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:P
Last Name:EASTRIDGE
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:PO BOX 69030
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-9030
Mailing Address - Country:US
Mailing Address - Phone:757-873-2302
Mailing Address - Fax:757-873-2306
Practice Address - Street 1:4214 FORTUNA CENTER PLZ
Practice Address - Street 2:
Practice Address - City:DUMFRIES
Practice Address - State:VA
Practice Address - Zip Code:22025-1515
Practice Address - Country:US
Practice Address - Phone:571-402-2098
Practice Address - Fax:571-888-8048
Is Sole Proprietor?:No
Enumeration Date:2014-07-31
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305208868225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05954OtherGROUP MEDICARE PTAN
VA1710395934OtherMEDICAID QMB
VAQ47525AMedicare PIN