Basic Information
| Provider Information | |||||||||
| NPI: | 1114264462 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 SILVER CROSS BLVD | ||||||||
| Address2: | |||||||||
| City: | NEW LENOX | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604519509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153007910 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1200 MAPLE RD | ||||||||
| Address2: | |||||||||
| City: | JOLIET | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604321439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157401100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2013 | ||||||||
| LastUpdateDate: | 01/07/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 209.010063 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.