Basic Information
| Provider Information | |||||||||
| NPI: | 1073961140 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NIEDZIELKO | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4530 E RAY RD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850446094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807591668 | ||||||||
| FaxNumber: | 4807591669 | ||||||||
| Practice Location | |||||||||
| Address1: | 4530 E RAY RD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850446094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807591668 | ||||||||
| FaxNumber: | 4807591669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2016 | ||||||||
| LastUpdateDate: | 05/31/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 12225 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251S0007X | 12225 | AZ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports | 2251X0800X | 12225 | AZ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.