Healthcare Provider Details

I. General information

NPI: 1033111430
Provider Name (Legal Business Name): MICHAEL G RYAN ANP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 W NATIONAL AVE
MILWAUKEE WI
53295-0001
US

IV. Provider business mailing address

1239 WILLIAMS DR
MUKWONAGO WI
53149-9537
US

V. Phone/Fax

Practice location:
  • Phone: 414-384-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF303185
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: