Basic Information
| Provider Information | |||||||||
| NPI: | 1821602178 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DERBY | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | MATTHEW | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1191 FORDHAM DRIVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283043774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104844653 | ||||||||
| FaxNumber: | 9104839256 | ||||||||
| Practice Location | |||||||||
| Address1: | 1191 FORDHAM DRIVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283043774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104844653 | ||||||||
| FaxNumber: | 9104839256 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2020 | ||||||||
| LastUpdateDate: | 05/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 046502 | NY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 1333741 | TX | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | P20003 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.