Provider Demographics
NPI:1770041949
Name:RYAN, LAURA A (PA-C)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:A
Last Name:RYAN
Suffix:
Gender:F
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 1:1503 N MOHAWK ST # 4E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-3038
Mailing Address - Country:US
Mailing Address - Phone:763-228-7098
Mailing Address - Fax:
Practice Address - Street 1:840 S WOOD ST STE 417
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4325
Practice Address - Country:US
Practice Address - Phone:312-996-4942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-06
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006956363AS0400X
MAPA100193363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant