Provider Demographics
NPI:1194343889
Name:AGUSTIN, RYANNE (PTA)
Entity type:Individual
Prefix:
First Name:RYANNE
Middle Name:
Last Name:AGUSTIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25428 N 63RD LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85083-1830
Mailing Address - Country:US
Mailing Address - Phone:561-312-9631
Mailing Address - Fax:
Practice Address - Street 1:16413 N 91ST ST
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-3048
Practice Address - Country:US
Practice Address - Phone:480-849-7911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ012767225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant