Provider Demographics
NPI:1821040536
Name:LIESKE, RYAN J (PA-C)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:J
Last Name:LIESKE
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 1:104 W SENECA ST
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:NE
Mailing Address - Zip Code:68869-1363
Mailing Address - Country:US
Mailing Address - Phone:308-452-3203
Mailing Address - Fax:308-452-3795
Practice Address - Street 1:104 W SENECA ST
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:NE
Practice Address - Zip Code:68869-1363
Practice Address - Country:US
Practice Address - Phone:308-452-3203
Practice Address - Fax:308-452-3795
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE767363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NES47895Medicare UPIN