Basic Information
| Provider Information | |||||||||
| NPI: | 1194030817 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | ELISE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 776351 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025889490 | ||||||||
| FaxNumber: | 5026296217 | ||||||||
| Practice Location | |||||||||
| Address1: | 3999 DUTCHMANS LANE | ||||||||
| Address2: | SUITE 6F | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5023945678 | ||||||||
| FaxNumber: | 5023945600 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2010 | ||||||||
| LastUpdateDate: | 03/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | TC417 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA2023 | 01 | KY | STATE LICENSE | OTHER | TC417 | 01 | KY | TEMP LICENSE | OTHER |