Provider Demographics
NPI:1215120589
Name:RYAN, LISA ANNE (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANNE
Last Name:RYAN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7412041
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2041
Mailing Address - Country:US
Mailing Address - Phone:314-453-9666
Mailing Address - Fax:314-453-9895
Practice Address - Street 1:226 S WOODS MILL RD
Practice Address - Street 2:STE 36W
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3662
Practice Address - Country:US
Practice Address - Phone:314-453-9666
Practice Address - Fax:314-453-9895
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007010576208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209458504Medicaid