Basic Information
| Provider Information | |||||||||
| NPI: | 1205942539 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOUSNER | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9500 BORMET DR STE 204 | ||||||||
| Address2: | |||||||||
| City: | MOKENA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604488399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083464044 | ||||||||
| FaxNumber: | 7083463287 | ||||||||
| Practice Location | |||||||||
| Address1: | 890 GARFIELD AVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | LIBERTYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600484723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479905636 | ||||||||
| FaxNumber: | 8476761549 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 2680-023 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | 10000873A | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | 085002765 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1205942539 | 05 | WI | MEDICAID |