Healthcare Provider Details

I. General information

NPI: 1104760065
Provider Name (Legal Business Name): RYAN BAKSH PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10560 SW VILLAGE PKWY
PORT SAINT LUCIE FL
34987-2359
US

IV. Provider business mailing address

1116 SW LAWNDALE AVE
PORT SAINT LUCIE FL
34953-7714
US

V. Phone/Fax

Practice location:
  • Phone: 772-446-0203
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA33562
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: