Healthcare Provider Details

I. General information

NPI: 1871618553
Provider Name (Legal Business Name): LAURIE R RYZNYK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURIE R WALTRIP

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W JACKSON ST SUITE 200
CARBONDALE IL
62901-1474
US

IV. Provider business mailing address

300 W OAK ST
CARBONDALE IL
62901-1400
US

V. Phone/Fax

Practice location:
  • Phone: 618-453-3777
  • Fax: 618-453-1102
Mailing address:
  • Phone: 618-536-6621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: