Provider Demographics
NPI:1265716690
Name:NUTTER, RYAN (PA-C)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:NUTTER
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 1:525 W RIVER WOODS PKWY STE 130
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1010
Mailing Address - Country:US
Mailing Address - Phone:414-961-0304
Mailing Address - Fax:414-961-0298
Practice Address - Street 1:525 W RIVER WOODS PKWY # 201
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-1024
Practice Address - Country:US
Practice Address - Phone:414-249-2422
Practice Address - Fax:414-249-0298
Is Sole Proprietor?:No
Enumeration Date:2011-10-04
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2773-023363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical