Provider Demographics
NPI:1750438313
Name:CARRELL, RYAN PAUL (PT)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:PAUL
Last Name:CARRELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:MR
Other - First Name:RYAN
Other - Middle Name:PAUL
Other - Last Name:CARRELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:1225 SIERRA LARGA NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112
Mailing Address - Country:US
Mailing Address - Phone:505-400-5380
Mailing Address - Fax:
Practice Address - Street 1:1225 SIERRA LARGA DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-6568
Practice Address - Country:US
Practice Address - Phone:505-400-5380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3356283X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital