Healthcare Provider Details

I. General information

NPI: 1255745857
Provider Name (Legal Business Name): KATIE LYNN RYAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. KATIE WALKOWIAK

II. Dates (important events)

Enumeration Date: 06/12/2014
Last Update Date: 06/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 E MICHIGAN AVE
LANSING MI
48912-1811
US

IV. Provider business mailing address

1718 GREENCREST AVE
EAST LANSING MI
48823-2910
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-1000
  • Fax:
Mailing address:
  • Phone: 989-450-3662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301105146
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: