Provider Demographics
NPI:1295454585
Name:PHELPS, RYAN MATTHEW (PTA)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:MATTHEW
Last Name:PHELPS
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 1:461 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NH
Mailing Address - Zip Code:03275-3105
Mailing Address - Country:US
Mailing Address - Phone:603-340-5386
Mailing Address - Fax:
Practice Address - Street 1:67 N MAIN ST # A
Practice Address - Street 2:
Practice Address - City:BOSCAWEN
Practice Address - State:NH
Practice Address - Zip Code:03303-1237
Practice Address - Country:US
Practice Address - Phone:603-753-2942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-22
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1443225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant