Provider Demographics
NPI:1801057765
Name:NALL, RYAN M
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:M
Last Name:NALL
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:PO BOX 52194
Mailing Address - Street 2:DEPT CODE 961
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85072-2194
Mailing Address - Country:US
Mailing Address - Phone:503-489-1781
Mailing Address - Fax:503-489-1650
Practice Address - Street 1:6700 NE 162ND AVE
Practice Address - Street 2:STE 411
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98682-3858
Practice Address - Country:US
Practice Address - Phone:360-567-0633
Practice Address - Fax:360-567-0635
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5697225100000X
WAPT60074448225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR142643Medicare PIN
ORR114778Medicare PIN
WAG8881055Medicare PIN
WAG8802660Medicare PIN
ORR114519Medicare PIN
ORR143894Medicare PIN
ORR114556Medicare PIN
ORR142154Medicare PIN
ORR143322Medicare PIN
ORR130647Medicare PIN