Basic Information
| Provider Information | |||||||||
| NPI: | 1306163571 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | CHRISTINE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARROW | ||||||||
| OtherFirstName: | MARIA | ||||||||
| OtherMiddleName: | CHRISTINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 15450 HIGHWAY 7 STE 125 | ||||||||
| Address2: | |||||||||
| City: | MINNETONKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553453522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635207870 | ||||||||
| FaxNumber: | 7635207888 | ||||||||
| Practice Location | |||||||||
| Address1: | 15450 HIGHWAY 7 STE 125 | ||||||||
| Address2: | |||||||||
| City: | MINNETONKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553453522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635207870 | ||||||||
| FaxNumber: | 7635207888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2010 | ||||||||
| LastUpdateDate: | 04/02/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 54065 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1306163571 | 05 | MN | MEDICAID |