Healthcare Provider Details

I. General information

NPI: 1104357425
Provider Name (Legal Business Name): RYAN PUCCIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 09/01/2023
Certification Date: 09/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 N MAYFAIR RD DEPT OF
WAUWATOSA WI
53226-3462
US

IV. Provider business mailing address

1155 N MAYFAIR RD DEPT OF
WAUWATOSA WI
53226-3462
US

V. Phone/Fax

Practice location:
  • Phone: 414-955-5990
  • Fax: 414-955-6282
Mailing address:
  • Phone: 414-955-5990
  • Fax: 414-955-6282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number70160
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number70160
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: