Healthcare Provider Details

I. General information

NPI: 1376793844
Provider Name (Legal Business Name): RYAN MALDONADO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2008
Last Update Date: 12/11/2008
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

6896 W SNOWVILLE RD
BRECKSVILLE OH
44141-3214
US

V. Phone/Fax

Practice location:
  • Phone: 517-337-0957
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005307
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: