Basic Information
| Provider Information | |||||||||
| NPI: | 1073089363 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GEORGE | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2901 W KINNICKINNIC RIVER PKWY STE 305 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532153660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146496000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2900 W OKLAHOMA AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532154330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146496000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2018 | ||||||||
| LastUpdateDate: | 11/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 100086732 | 05 | WI | MEDICAID |