Healthcare Provider Details

I. General information

NPI: 1861229700
Provider Name (Legal Business Name): RYAN J ACKS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2024
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4660 S HAGADORN RD STE 420
EAST LANSING MI
48823-5353
US

IV. Provider business mailing address

804 SERVICE RD STE A202
EAST LANSING MI
48824-7015
US

V. Phone/Fax

Practice location:
  • Phone: 517-884-6100
  • Fax: 517-884-6233
Mailing address:
  • Phone: 517-884-6100
  • Fax: 517-884-6233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601012663
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: