Provider Demographics
NPI:1457773053
Name:DECKINGA, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:DECKINGA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6406 21ST AVE W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-7850
Mailing Address - Country:US
Mailing Address - Phone:941-798-8712
Mailing Address - Fax:941-798-8829
Practice Address - Street 1:6406 21ST AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-7850
Practice Address - Country:US
Practice Address - Phone:941-798-8712
Practice Address - Fax:941-798-8829
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-16
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA21067225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant