Provider Demographics
NPI:1114335973
Name:STROM, RYAN EDWARD (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:EDWARD
Last Name:STROM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 N ADELAIDE ST
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-2663
Mailing Address - Country:US
Mailing Address - Phone:810-629-2245
Mailing Address - Fax:810-593-1029
Practice Address - Street 1:6333 S EAST ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-7107
Practice Address - Country:US
Practice Address - Phone:800-526-9252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-24
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001701A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical