Provider Demographics
NPI:1619506714
Name:KOTTMEIER, RYAN JOHN (PA)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:JOHN
Last Name:KOTTMEIER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 TRIANGLE DR
Mailing Address - Street 2:
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-1431
Mailing Address - Country:US
Mailing Address - Phone:631-278-3410
Mailing Address - Fax:
Practice Address - Street 1:101 NICOLLS ROAD SUNY STONY BROOK HOSPITAL
Practice Address - Street 2:DEPT OF ORTHOPEDICS HSC T18, ROOM 080
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794
Practice Address - Country:US
Practice Address - Phone:631-444-1478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-02
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024921363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant