Provider Demographics
NPI:1104357425
Name:PUCCIA, RYAN (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:PUCCIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 N MAYFAIR RD DEPT OF
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3462
Mailing Address - Country:US
Mailing Address - Phone:414-955-5990
Mailing Address - Fax:414-955-6282
Practice Address - Street 1:1155 N MAYFAIR RD DEPT OF
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3462
Practice Address - Country:US
Practice Address - Phone:414-955-5990
Practice Address - Fax:414-955-6282
Is Sole Proprietor?:No
Enumeration Date:2017-03-27
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI70160207YS0123X, 207Y00000X, 207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1104357425Medicaid