Provider Demographics
NPI:1780708388
Name:MARTIN, RYAN (DPT)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:
Last Name:MARTIN
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 1:63-17 METROPOLITAN AVENUE
Mailing Address - Street 2:
Mailing Address - City:MIDDLE VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11379
Mailing Address - Country:US
Mailing Address - Phone:718-554-6610
Mailing Address - Fax:718-360-4908
Practice Address - Street 1:63-17 METROPOLITAN AVENUE
Practice Address - Street 2:
Practice Address - City:MIDDLE VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11379
Practice Address - Country:US
Practice Address - Phone:718-554-6610
Practice Address - Fax:718-360-4908
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028643225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02944085Medicaid
NY02944085Medicaid