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General NPI Number Information
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NPI Number | 1205033610
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Entity Type | Individual
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Provider Name | MELISSA AUTUMN RYAN CST,CFA,RSA
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Gender | Female
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Dates
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Enumeration Date | 06/29/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 300 RANDALL RD
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City | GENEVA
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State | IL
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Zip | 60134-4200
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Country | US
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Telephone | 630-208-4050
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Fax |
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Provider Business Mailing Address
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Address Line | 48W741 LENSCHOW RD
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City | HAMPSHIRE
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State | IL
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Zip | 60140-8672
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Country | US
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Telephone | 847-683-9113
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Fax | 847-683-9113
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number |
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License Number State | IL
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