Provider Demographics
NPI:1598771412
Name:RYAN, LUCAS A (PA-C)
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:A
Last Name:RYAN
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 1:325 PRINCETON AVE
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08540-1617
Mailing Address - Country:US
Mailing Address - Phone:609-924-8131
Mailing Address - Fax:609-924-8532
Practice Address - Street 1:325 PRINCETON AVE
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08540-1617
Practice Address - Country:US
Practice Address - Phone:609-924-8131
Practice Address - Fax:609-683-7559
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00122300363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ083210ACDMedicare ID - Type Unspecified
NJP43718Medicare UPIN