Healthcare Provider Details

I. General information

NPI: 1891032439
Provider Name (Legal Business Name): RYAN C UPSON NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2013
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3475 BELLE CHASE WAY
LANSING MI
48911-4252
US

IV. Provider business mailing address

812 E JOLLY RD SUITE 210
LANSING MI
48910-6818
US

V. Phone/Fax

Practice location:
  • Phone: 517-882-3732
  • Fax:
Mailing address:
  • Phone: 514-346-8000
  • Fax: 514-346-8291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704234352
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: