Provider Demographics
NPI:1528013745
Name:SMITH, RYAN G (PA)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:G
Last Name:SMITH
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Gender:M
Credentials:PA
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Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:PEDIATRIC CARDIOTHORACIC SURGERY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-2380
Mailing Address - Fax:414-266-2294
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:PEDIATRIC CARDIOTHORACIC SURGERY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-2380
Practice Address - Fax:414-266-2294
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2014-10-17
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Provider Licenses
StateLicense IDTaxonomies
WI1995363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1528013745Medicaid
WI680860722Medicare PIN
WI1528013745Medicaid