Healthcare Provider Details

I. General information

NPI: 1528526993
Provider Name (Legal Business Name): RYAN MICHAEL LYSNE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2019
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W 5TH AVE STE 400
SPOKANE WA
99204-2715
US

IV. Provider business mailing address

601 W 5TH AVE STE 400
SPOKANE WA
99204-2715
US

V. Phone/Fax

Practice location:
  • Phone: 509-344-2663
  • Fax: 509-624-9179
Mailing address:
  • Phone: 509-344-2663
  • Fax: 509-624-9179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberTA60987863
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60964856
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: