Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 12225 | AZ |
N | 2251S0007X | Physical Therapist - Sports | 12225 | AZ |
N | 2251X0800X | Physical Therapist - Orthopedic | 12225 | AZ |
NPI | 1073961140 |
---|---|
Provider Name | Dr. Ryan Niedzielko |
First Address | Phoenix, AZ 85044-6094 |
Second Address | Phoenix, AZ 85044-6094 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/05/2016 |
Last Update Date | 31/05/2016 |