Provider Demographics
NPI:1114300332
Name:RYAN, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 PROMENADE LN
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-1924
Mailing Address - Country:US
Mailing Address - Phone:716-440-4117
Mailing Address - Fax:
Practice Address - Street 1:2851 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-5855
Practice Address - Country:US
Practice Address - Phone:716-440-4117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY060491261QV0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QV0200XAmbulatory Health Care FacilitiesClinic/CenterVA
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY060491OtherNEW YORK STATE PHARMACIST LICENSE NUMBER