Provider Demographics
NPI:1386298164
Name:TIRELLA, RYAN ANTHONY (PTA)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:ANTHONY
Last Name:TIRELLA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 ASHLAND AVE APT 307
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-5566
Mailing Address - Country:US
Mailing Address - Phone:908-285-4515
Mailing Address - Fax:
Practice Address - Street 1:479 UNION AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:08807-3143
Practice Address - Country:US
Practice Address - Phone:908-203-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00362700225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant