Provider Demographics
NPI:1316297369
Name:BOLENA, RYAN E (DPT)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:E
Last Name:BOLENA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 MAMARONECK AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10605-5224
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1561 COMMERCE RD STE 402
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:VA
Practice Address - Zip Code:24482
Practice Address - Country:US
Practice Address - Phone:540-416-0530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-18
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13774225100000X
VA2305207785225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC018TEOtherNORTH CAROLINA BLUE CROSS BLUE SHIELD