Provider Demographics
NPI:1710457718
Name:RYAN, BRANDON WILLIAM
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:WILLIAM
Last Name:RYAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8872 PROFESSIONAL DR STE B
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-8482
Mailing Address - Country:US
Mailing Address - Phone:231-779-0320
Mailing Address - Fax:
Practice Address - Street 1:8872 PROFESSIONAL DR STE B
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-8482
Practice Address - Country:US
Practice Address - Phone:231-779-0320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-03
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2562363L00000X
MI4704257968363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner