Provider Demographics
NPI:1164775995
Name:LINDEMANN, RYAN WILLIS
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:WILLIS
Last Name:LINDEMANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 GEORGE ST APT 534
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-6703
Mailing Address - Country:US
Mailing Address - Phone:940-867-0959
Mailing Address - Fax:
Practice Address - Street 1:207 GEORGE ST APT 534
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-6703
Practice Address - Country:US
Practice Address - Phone:940-867-0959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-17
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT092460163W00000X
TX732793163W00000X
CT5223367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse