Healthcare Provider Details

I. General information

NPI: 1750438313
Provider Name (Legal Business Name): RYAN PAUL CARRELL PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: RYAN PAUL CARRELL PT

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 SIERRA LARGA DR NE
ALBUQUERQUE NM
87112-6568
US

IV. Provider business mailing address

1225 SIERRA LARGA NE
ALBUQUERQUE NM
87112
US

V. Phone/Fax

Practice location:
  • Phone: 505-400-5380
  • Fax:
Mailing address:
  • Phone: 505-400-5380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number3356
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: