Provider Demographics
NPI:1255745857
Name:RYAN, KATIE LYNN (MD)
Entity type:Individual
Prefix:DR
First Name:KATIE
Middle Name:LYNN
Last Name:RYAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:WALKOWIAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1718 GREENCREST AVE
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-2910
Mailing Address - Country:US
Mailing Address - Phone:989-450-3662
Mailing Address - Fax:
Practice Address - Street 1:1215 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1811
Practice Address - Country:US
Practice Address - Phone:517-364-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-12
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301105146207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301105146OtherSTATE OF MICHIGAN