=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972051019
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA RYAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2016
-----------------------------------------------------
Last Update Date | 09/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 411 W LAKE LANSING RD STE C120
-----------------------------------------------------
City | EAST LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48823-8483
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-337-0957
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 411 W LAKE LANSING RD STE C120
-----------------------------------------------------
City | EAST LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48823-8483
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-337-0957
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 5601007877
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------