Provider Demographics
NPI:1871932491
Name:WILLIS, RYAN (DPT)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5904 159TH AVE E
Mailing Address - Street 2:APT C
Mailing Address - City:SUMNER
Mailing Address - State:WA
Mailing Address - Zip Code:98390-3322
Mailing Address - Country:US
Mailing Address - Phone:971-678-1755
Mailing Address - Fax:
Practice Address - Street 1:2726 GRIFFIN AVE
Practice Address - Street 2:SUITE C
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-2362
Practice Address - Country:US
Practice Address - Phone:360-802-6757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60366827225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist