Provider Demographics
NPI:1730146812
Name:MINICK, RYAN P (MPT)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:P
Last Name:MINICK
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2117 LOMBARDY CIR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-6061
Mailing Address - Country:US
Mailing Address - Phone:704-996-2030
Mailing Address - Fax:
Practice Address - Street 1:1809 EAST BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5879
Practice Address - Country:US
Practice Address - Phone:704-374-1811
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10305225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist