Provider Demographics
NPI:1801138904
Name:RYAN, LAUREN R (PA-C)
Entity type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:R
Last Name:RYAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:R
Other - Last Name:KETTERER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1000 DUTCH RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:PA
Mailing Address - Zip Code:15009-9727
Mailing Address - Country:US
Mailing Address - Phone:724-773-3464
Mailing Address - Fax:247-733-4657
Practice Address - Street 1:1000 DUTCH RIDGE RD
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:PA
Practice Address - Zip Code:15009-9727
Practice Address - Country:US
Practice Address - Phone:724-773-3464
Practice Address - Fax:724-773-3465
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1102168363AS0400X
PAMA056089208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA325201Medicare PIN