Basic Information
| Provider Information | |||||||||
| NPI: | 1104222793 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LADUKE | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | CAVANAUGH | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 ELMWOOD AVE BOX 655A | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852752100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 601 ELMWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852752100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2014 | ||||||||
| LastUpdateDate: | 05/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA031095 | DC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 023917 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207P00000X | PA031095 | DC | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 023917 | 01 | NY | THE UNIVERSITY OF THE STATE OF NEW YORK EDUCATION DEPARTMENT | OTHER | CA1400053 | 01 | DC | CONTROLLED SUBSTANCE LICESNE | OTHER | PA031095 | 01 | DC | PHYSICIAN ASSISTANT LICENSE | OTHER |