Provider Demographics
NPI:1821654054
Name:RYAN, SAMANTHA L (PTA)
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:L
Last Name:RYAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2061 NW COWGIRL WAY
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-4501
Mailing Address - Country:US
Mailing Address - Phone:360-536-0328
Mailing Address - Fax:
Practice Address - Street 1:840 MADISON AVE N
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-1769
Practice Address - Country:US
Practice Address - Phone:206-855-0955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-13
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60936457225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant