Provider Demographics
NPI:1760052351
Name:GLACKEN, RYAN PATRICK (PTA)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:PATRICK
Last Name:GLACKEN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 W OLIVE ST STE 118
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18508-2576
Mailing Address - Country:US
Mailing Address - Phone:570-209-7604
Mailing Address - Fax:
Practice Address - Street 1:3 W OLIVE ST STE 118
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18508-2576
Practice Address - Country:US
Practice Address - Phone:570-209-7604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE012684225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant