Healthcare Provider Details

I. General information

NPI: 1811600596
Provider Name (Legal Business Name): SHANNON LOUISE RYAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2022
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 S HIGHLAND AVE STE 204C
LOMBARD IL
60148-6193
US

IV. Provider business mailing address

1919 S HIGHLAND AVE STE 204C
LOMBARD IL
60148-6193
US

V. Phone/Fax

Practice location:
  • Phone: 708-848-4662
  • Fax: 708-613-4319
Mailing address:
  • Phone: 708-848-4662
  • Fax: 708-613-4319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601011451
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085011572
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: