MEDICARE: JUSTINE CAROTENUTI-RYAN PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	5161	AZ

General Provider Information

NPI Number	:	1255925996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTINE CAROTENUTI-RYAN PT, DPT

Provider Business Mailing Address
First Line	:	22310 N 94TH LN
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85383-2955
Country	:	US
Telephone Number	:	602-799-7713
Fax Number	:

Provider Business Practice Location Address
First Line	:	13840 N DESERT HARBOR DR
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85381-3501
Country	:	US
Telephone Number	:	623-972-0995
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/23/2021
Last Update Date	:	02/23/2021

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