Provider Demographics
NPI:1902155344
Name:MARTIN, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:MARTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4650 E COTTON CENTER BLVD STE 250
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85040-4806
Mailing Address - Country:US
Mailing Address - Phone:480-779-4672
Mailing Address - Fax:480-272-8945
Practice Address - Street 1:8410 W THOMAS RD STE 136
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-3374
Practice Address - Country:US
Practice Address - Phone:623-247-4478
Practice Address - Fax:623-247-7839
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI3537225100000X
AZ10665225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist