Provider Demographics
NPI:1952060733
Name:SYSOL, JASON RYAN (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:RYAN
Last Name:SYSOL
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:1500 E MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-5000
Practice Address - Country:US
Practice Address - Phone:734-936-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-09
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI363LA2100X363LA2100X, 363LA2100X
MI4704323910363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner