Provider Demographics
NPI:1205942539
Name:HOUSNER, RYAN JOSEPH (PA-C)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:JOSEPH
Last Name:HOUSNER
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:9500 BORMET DR STE 204
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8399
Mailing Address - Country:US
Mailing Address - Phone:708-346-4044
Mailing Address - Fax:708-346-3287
Practice Address - Street 1:890 GARFIELD AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-4723
Practice Address - Country:US
Practice Address - Phone:847-990-5636
Practice Address - Fax:847-676-1549
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI2680-023363AS0400X
IN10000873A363AS0400X
IL085002765363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1205942539Medicaid
ILP00352628Medicare PIN
ILQ71523Medicare UPIN
WI1205942539Medicaid