Healthcare Provider Details

I. General information

NPI: 1265716690
Provider Name (Legal Business Name): RYAN NUTTER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2011
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 W RIVER WOODS PKWY # 201
MILWAUKEE WI
53212-1024
US

IV. Provider business mailing address

525 W RIVER WOODS PKWY STE 130
GLENDALE WI
53212-1010
US

V. Phone/Fax

Practice location:
  • Phone: 414-249-2422
  • Fax: 414-249-0298
Mailing address:
  • Phone: 414-961-0304
  • Fax: 414-961-0298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number2773-023
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: