Provider Demographics
NPI:1932700101
Name:RYAN, BLAKE WILLIAM (DPT)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:WILLIAM
Last Name:RYAN
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 1:375 WALNUT AVE APT C
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-3171
Mailing Address - Country:US
Mailing Address - Phone:909-260-2643
Mailing Address - Fax:
Practice Address - Street 1:26831 ALISO CREEK RD STE 200
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-5341
Practice Address - Country:US
Practice Address - Phone:949-382-1909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA298638225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist