Basic Information
| Provider Information | |||||||||
| NPI: | 1932185907 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RYLANDER | ||||||||
| FirstName: | LUKE | ||||||||
| MiddleName: | BENNETT | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2545 CHICAGO AVE | ||||||||
| Address2: | SUITE 601 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554044522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128637770 | ||||||||
| FaxNumber: | 6128637772 | ||||||||
| Practice Location | |||||||||
| Address1: | 2855 CAMPUS DR | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554412649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635777160 | ||||||||
| FaxNumber: | 7635777074 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2005 | ||||||||
| LastUpdateDate: | 10/25/2017 | ||||||||
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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 | 363A00000X | 9702 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 41956100 | 05 | WI | MEDICAID | 374820100 | 05 | MN | MEDICAID |