Provider Demographics
NPI:1962465658
Name:PRETZ, RYAN R (PT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:R
Last Name:PRETZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 411277
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141
Mailing Address - Country:US
Mailing Address - Phone:573-712-2280
Mailing Address - Fax:
Practice Address - Street 1:3999 HIGHWAY PP STE 2
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-9130
Practice Address - Country:US
Practice Address - Phone:573-712-2280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004007960225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO489274001Medicaid
MOP00607881OtherPALMETTO GBA
MO217891511Medicare PIN
MO489274001Medicaid
MOP00607881OtherPALMETTO GBA
MO217891706Medicare ID - Type Unspecified