Provider Demographics
NPI:1982741195
Name:LEISY, RYAN (DC)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:LEISY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 26
Mailing Address - Street 2:
Mailing Address - City:KOOTENAI
Mailing Address - State:ID
Mailing Address - Zip Code:83840-5055
Mailing Address - Country:US
Mailing Address - Phone:208-265-1900
Mailing Address - Fax:
Practice Address - Street 1:30544 HIGHWAY 200 STE 330
Practice Address - Street 2:
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852-5005
Practice Address - Country:US
Practice Address - Phone:208-265-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH34717111N00000X
IDCHIA-1250111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAV12049Medicare UPIN
WA8864814Medicare PIN