Provider Demographics
NPI:1457759342
Name:DEAN, RYAN (PA, AT)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:DEAN
Suffix:
Gender:M
Credentials:PA, AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18115 LAKEVIEW DR APT 102
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-5670
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2900 W OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4330
Practice Address - Country:US
Practice Address - Phone:307-760-2624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-09
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAT.00012512255A2300X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100294074Medicaid