Basic Information
| Provider Information | |||||||||
| NPI: | 1376145144 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DISHAW | ||||||||
| FirstName: | RYAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 576 BROADHOLLOW RD | ||||||||
| Address2: | |||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117475002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313595859 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 PETERSVILLE RD STE 3 | ||||||||
| Address2: | |||||||||
| City: | NEW ROCHELLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 108014465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146365595 | ||||||||
| FaxNumber: | 9146365598 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2020 | ||||||||
| LastUpdateDate: | 11/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.