Healthcare Provider Details

I. General information

NPI: 1669522488
Provider Name (Legal Business Name): MR. RYAN MATTHEW WILKERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 BRANDYWINE ST NW STE 301
WASHINGTON DC
20016-1876
US

IV. Provider business mailing address

PO BOX 392573
PITTSBURGH PA
15251-9573
US

V. Phone/Fax

Practice location:
  • Phone: 202-516-5697
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number19982
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT2000017
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: