Basic Information
| Provider Information | |||||||||
| NPI: | 1598768194 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 54249 SOUTH SAND ROAD | ||||||||
| Address2: | |||||||||
| City: | STURGEON LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2184854936 | ||||||||
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| Practice Location | |||||||||
| Address1: | 512 SKYLINE BLVD STE 1 | ||||||||
| Address2: | |||||||||
| City: | CLOQUET | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557201199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188794641 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 11/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 34503 | MN | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 963826100 | 05 | MN | MEDICAID |