Provider Demographics
NPI:1306067426
Name:RANSOM, RAYMOND WADE (ATC, PTA)
Entity type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:WADE
Last Name:RANSOM
Suffix:
Gender:M
Credentials:ATC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 PLEASANTVIEW DR
Mailing Address - Street 2:APT. A
Mailing Address - City:PISCATAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08854-3446
Mailing Address - Country:US
Mailing Address - Phone:732-424-6410
Mailing Address - Fax:
Practice Address - Street 1:400 S ORANGE AVE
Practice Address - Street 2:RECREATION CENTER
Practice Address - City:SOUTH ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07079-2646
Practice Address - Country:US
Practice Address - Phone:973-313-6394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00190100225200000X
NJ25MT001387002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer