Provider Demographics
NPI:1285605550
Name:RYAN, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:RYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04009-1156
Mailing Address - Country:US
Mailing Address - Phone:207-647-4232
Mailing Address - Fax:207-647-6016
Practice Address - Street 1:25 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:BRIDGTON
Practice Address - State:ME
Practice Address - Zip Code:04009-1156
Practice Address - Country:US
Practice Address - Phone:207-647-4232
Practice Address - Fax:207-647-6016
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1559208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM8534Medicare ID - Type Unspecified
MEG12353Medicare UPIN