Provider Demographics
NPI:1215934583
Name:MAHAR, RYAN P (PT)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:P
Last Name:MAHAR
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 1:28 4TH ST
Mailing Address - Street 2:
Mailing Address - City:FAIR HAVEN
Mailing Address - State:VT
Mailing Address - Zip Code:05743-1053
Mailing Address - Country:US
Mailing Address - Phone:802-265-4055
Mailing Address - Fax:802-265-8838
Practice Address - Street 1:28 4TH ST
Practice Address - Street 2:
Practice Address - City:FAIR HAVEN
Practice Address - State:VT
Practice Address - Zip Code:05743-1053
Practice Address - Country:US
Practice Address - Phone:802-265-4055
Practice Address - Fax:802-265-8838
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2015-10-30
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
NY017392-1225100000X
VT040-0003124225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN2517Medicaid
NYBB5758Medicare ID - Type UnspecifiedUPSTATE MEDICARE DIVISION
NYVN2517Medicare ID - Type UnspecifiedNHIC