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General NPI Number Information
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NPI Number | 1629501606
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Entity Type | Individual
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Provider Name | RYAN TATE PTA
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Gender | Male
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Dates
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Enumeration Date | 04/06/2017
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Last Update Date | 04/06/2017
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Provider Practice Location Address
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Address Line | 1539 MCHENRY AVE
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City | MODESTO
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State | CA
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Zip | 95350-4528
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Country | US
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Telephone | 209-578-3290
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Fax | 209-529-8643
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Provider Business Mailing Address
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Address Line | 1539 MCHENRY AVE
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City | MODESTO
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State | CA
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Zip | 95350-4528
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Country | US
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Telephone | 209-578-3290
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Fax | 209-529-8643
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | PTA 10561
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License Number State | CA
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