Basic Information
| Provider Information | |||||||||
| NPI: | 1306466479 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTINI | ||||||||
| FirstName: | RYAN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21346 SAGE BRUSH LN | ||||||||
| Address2: | |||||||||
| City: | MOKENA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604481486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087387259 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3691 WILLOWCREEK RD | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463685080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199211444 | ||||||||
| FaxNumber: | 2199215303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2020 | ||||||||
| LastUpdateDate: | 05/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.