Provider Demographics
NPI:1194030817
Name:RYAN, ANDREA ELISE (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:ELISE
Last Name:RYAN
Suffix:
Gender:F
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-629-6217
Practice Address - Street 1:3999 DUTCHMANS LANE
Practice Address - Street 2:SUITE 6F
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4929
Practice Address - Country:US
Practice Address - Phone:502-394-5678
Practice Address - Fax:502-394-5600
Is Sole Proprietor?:No
Enumeration Date:2010-08-18
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC417363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYPA2023OtherSTATE LICENSE
KYTC417OtherTEMP LICENSE