Provider Demographics
NPI:1790257293
Name:POPE, RYAN (DPT)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:POPE
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 1:5273 WHITAKER RD
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-1617
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3190 E MERIDIAN PARK LOOP STE 206
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7422
Practice Address - Country:US
Practice Address - Phone:907-373-9462
Practice Address - Fax:907-373-9464
Is Sole Proprietor?:No
Enumeration Date:2018-12-20
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
MSPT6575225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE