Healthcare Provider Details

I. General information

NPI: 1144518879
Provider Name (Legal Business Name): RYAN J HERMUS APNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2011
Last Update Date: 05/02/2024
Certification Date: 05/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3925 N GATEWAY DR
APPLETON WI
54913-7863
US

IV. Provider business mailing address

3925 N GATEWAY DR
APPLETON WI
54913-7863
US

V. Phone/Fax

Practice location:
  • Phone: 920-454-8401
  • Fax: 920-993-5037
Mailing address:
  • Phone: 920-454-8401
  • Fax: 920-993-5037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number158574-30
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4537-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: