Provider Demographics
NPI:1841230984
Name:FARR, RYAN ELLSWORTH (PT)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:ELLSWORTH
Last Name:FARR
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 1:921 TIMBERLINE DR
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-8299
Mailing Address - Country:US
Mailing Address - Phone:541-412-7906
Mailing Address - Fax:707-464-9974
Practice Address - Street 1:1485 NORTHCREST DR
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-2324
Practice Address - Country:US
Practice Address - Phone:707-464-9958
Practice Address - Fax:707-464-9974
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT26976225100000X
OR3958225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0269760Medicaid
CA0PT269760OtherBLUE SHIELD
CA4563670001OtherDMERC
CAPT0269760Medicaid
CAP51286Medicare UPIN