Provider Demographics
NPI:1043708472
Name:LUNDBERG, JOSEPH RYAN (CSFA)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:RYAN
Last Name:LUNDBERG
Suffix:
Gender:M
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7040 WESTHAVEN CIR APT 104
Mailing Address - Street 2:
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077-7758
Mailing Address - Country:US
Mailing Address - Phone:231-492-6212
Mailing Address - Fax:
Practice Address - Street 1:8433 HARCOURT RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2190
Practice Address - Country:US
Practice Address - Phone:317-583-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
167278246ZC0007X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant