MEDICARE: RYAN EDWARD ELASSAL PT

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	5329	OK
2	332B00000X	Durable Medical Equipment & Medical Supplies	1-E-8553	OK

General Provider Information

NPI Number	:	1417587676
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN EDWARD ELASSAL PT

Provider Business Mailing Address
First Line	:	16905 HALBROOKE CIR
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73012-6864
Country	:	US
Telephone Number	:	405-996-0660
Fax Number	:

Provider Business Practice Location Address
First Line	:	7919 MID AMERICA BLVD STE 100
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73135-6611
Country	:	US
Telephone Number	:	405-736-0064
Fax Number	:

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

Provider Enumeration Date	:	01/16/2020
Last Update Date	:	09/24/2024

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