Basic Information
| Provider Information | |||||||||
| NPI: | 1497284475 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUSLIG | ||||||||
| FirstName: | RYAN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3231 S NATIONAL AVE | ||||||||
| Address2: | STE 280 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658077304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8554207900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3231 S NATIONAL AVE STE 140 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658077304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178904132 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2017 | ||||||||
| LastUpdateDate: | 07/14/2017 | ||||||||
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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 | 163W00000X | 2014005849 | MO | N | Nursing Service Providers | Registered Nurse | 363LG0600X | 2017024422 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 01 | MO | MEDICARE | OTHER | PENDING | 05 | MO | MEDICAID | PENDING | 05 | AR | MEDICAID |