Provider Demographics
NPI:1417591348
Name:RYCKMAN, MIA LAUREN (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MS
First Name:MIA
Middle Name:LAUREN
Last Name:RYCKMAN
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
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Mailing Address - Street 1:875 S DOBSON RD
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-5710
Mailing Address - Country:US
Mailing Address - Phone:480-899-9800
Mailing Address - Fax:480-899-2994
Practice Address - Street 1:875 S DOBSON RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5710
Practice Address - Country:US
Practice Address - Phone:480-899-9800
Practice Address - Fax:480-899-2994
Is Sole Proprietor?:No
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ7560363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant