Provider Demographics
NPI:1891077053
Name:MCNEIL, RYAN FREDERIC (DPT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:FREDERIC
Last Name:MCNEIL
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 1:65 E WADSWORTH PARK DR STE 230
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-8096
Mailing Address - Country:US
Mailing Address - Phone:385-308-8034
Mailing Address - Fax:
Practice Address - Street 1:65 E WADSWORTH PARK DR STE 230
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-8096
Practice Address - Country:US
Practice Address - Phone:385-308-8034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-14
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR06615225100000X
COPTL.0012590225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500639158Medicaid
WAP01197266OtherRR MEDICARE
OR500639158Medicaid