Provider Demographics
NPI:1841532850
Name:STEWART, RYAN (PT)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:
Last Name:STEWART
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 1:558 ALAMO ST
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-7601
Mailing Address - Country:US
Mailing Address - Phone:208-904-0165
Mailing Address - Fax:
Practice Address - Street 1:1800 FLANDRO DR STE 190
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83202-4940
Practice Address - Country:US
Practice Address - Phone:208-233-2248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-18
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-3077225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist