Provider Demographics
NPI:1831531045
Name:RYAN, LISA MARIE (AGPCNP-BC)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:RYAN
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 MILTON ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-5327
Mailing Address - Country:US
Mailing Address - Phone:781-956-2666
Mailing Address - Fax:
Practice Address - Street 1:320 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NORTH EASTON
Practice Address - State:MA
Practice Address - Zip Code:02357-1168
Practice Address - Country:US
Practice Address - Phone:508-565-1307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-29
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2013011857363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology