Provider Demographics
NPI:1285792143
Name:RYAN, JESSE THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:JESSE
Middle Name:THOMAS
Last Name:RYAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 E ADAMS ST RM 241
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2306
Mailing Address - Country:US
Mailing Address - Phone:315-464-4636
Mailing Address - Fax:
Practice Address - Street 1:5100 W TAFT RD STE 3E
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-3809
Practice Address - Country:US
Practice Address - Phone:315-452-2350
Practice Address - Fax:315-452-2355
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101240508207Y00000X
ND12940207Y00000X
MI4301104789207Y00000X
NY279632-1207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND18856Medicaid
NDN719392Medicare PIN
ND18856Medicaid