Provider Demographics
NPI:1285955583
Name:MCCORMICK, RYAN PATRICK (PT, DPT)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:PATRICK
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 FALLS AVE E STE 401
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3455
Mailing Address - Country:US
Mailing Address - Phone:208-969-9945
Mailing Address - Fax:208-944-0488
Practice Address - Street 1:1945 HILAND AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2714
Practice Address - Country:US
Practice Address - Phone:208-647-0024
Practice Address - Fax:208-647-0239
Is Sole Proprietor?:No
Enumeration Date:2010-06-21
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1204093225100000X
ID7649225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX165348701Medicaid
FLPT25574Medicaid
TX456643Medicare Oscar/Certification
TX456643Medicare PIN