Basic Information
| Provider Information | |||||||||
| NPI: | 1649482910 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUSSENDEN | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8395 W OAKLAND PARK BLVD | ||||||||
| Address2: | SUITE E AND F | ||||||||
| City: | SUNRISE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333517301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544721322 | ||||||||
| FaxNumber: | 9543703420 | ||||||||
| Practice Location | |||||||||
| Address1: | 1095 MARSHALL WAY STE 202 | ||||||||
| Address2: | |||||||||
| City: | PLACERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956675722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306263628 | ||||||||
| FaxNumber: | 5307480335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 208600000X | A105216 | CA | Y | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 247573 | MA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 49793 | MN | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | ME113403 | FL | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 539182000 | 05 | MN | MEDICAID |