Provider Demographics
NPI:1174148712
Name:RYAN, JUSTIN (FNP-C)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:RYAN
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3175 SMITH RD
Mailing Address - Street 2:
Mailing Address - City:LAMBERTVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48144-9434
Mailing Address - Country:US
Mailing Address - Phone:734-856-5494
Mailing Address - Fax:
Practice Address - Street 1:3175 SMITH RD
Practice Address - Street 2:
Practice Address - City:LAMBERTVILLE
Practice Address - State:MI
Practice Address - Zip Code:48144-9434
Practice Address - Country:US
Practice Address - Phone:734-856-5494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.404739163W00000X
MI4704350098163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse