MEDICARE: MRS. CANDICE B RYAN PTA

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	225200000X	Physical Therapy Assistant	1400	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1400	OTHER	OK	LICENSE #

General Provider Information

NPI Number	:	1720198690
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CANDICE B RYAN PTA

Provider Business Mailing Address
First Line	:	1202 MERRICK DRIVE
Second Line	:
City	:	ARDMORE
State	:	OK
Zip	:	73401
Country	:	US
Telephone Number	:	580-226-6754
Fax Number	:	580-226-0394

Provider Business Practice Location Address
First Line	:	1202 MERRICK DR
Second Line	:
City	:	ARDMORE
State	:	OK
Zip	:	73401-1824
Country	:	US
Telephone Number	:	580-226-6754
Fax Number	:

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	12/28/2007

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