Provider Demographics
NPI:1982858999
Name:MAKUCK, RYAN F (PA-C)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:F
Last Name:MAKUCK
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 1:3334 TOWN BROOKE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-6611
Mailing Address - Country:US
Mailing Address - Phone:860-632-8191
Mailing Address - Fax:
Practice Address - Street 1:201 CHESTNUT HILL RD
Practice Address - Street 2:
Practice Address - City:STAFFORD SPRINGS
Practice Address - State:CT
Practice Address - Zip Code:06076-4005
Practice Address - Country:US
Practice Address - Phone:860-749-2201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002203363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant