Healthcare Provider Details

I. General information

NPI: 1255868006
Provider Name (Legal Business Name): RYAN J MONCADA P.A
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 05/16/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 DELAFIELD ST SUITE 207
WAUKESHA WI
53188-3417
US

IV. Provider business mailing address

1334 ROCKRIDGE RD APARTMENT #342
WAUKESHA WI
53188-2897
US

V. Phone/Fax

Practice location:
  • Phone: 262-446-3593
  • Fax:
Mailing address:
  • Phone: 262-227-1323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4108
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: