Provider Demographics
NPI:1184795254
Name:LANDY, RYAN (PT)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:
Last Name:LANDY
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 1:700 PARK REGENCY PL NE
Mailing Address - Street 2:1004
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30326-1271
Mailing Address - Country:US
Mailing Address - Phone:404-353-7759
Mailing Address - Fax:
Practice Address - Street 1:1508 ROCK QUARRY RD
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-5047
Practice Address - Country:US
Practice Address - Phone:770-507-3233
Practice Address - Fax:770-507-4118
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-12
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004530225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA428852177AMedicaid
GAS35635Medicare UPIN
GA65BBBBDMedicare ID - Type Unspecified