Provider Demographics
NPI:1811105786
Name:RYAN, STEPHAN B (AUD CCC-A)
Entity type:Individual
Prefix:DR
First Name:STEPHAN
Middle Name:B
Last Name:RYAN
Suffix:
Gender:M
Credentials:AUD CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11649 N PORT WASHINGTON RD
Mailing Address - Street 2:AUDIOLOGY HEARING CLINIC OF MEQUON LLC
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-3460
Mailing Address - Country:US
Mailing Address - Phone:262-241-3144
Mailing Address - Fax:262-241-3186
Practice Address - Street 1:11649 N PORT WASHINGTON RD
Practice Address - Street 2:AUDIOLOGY HEARING CLINIC OF MEQUON LLC
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3460
Practice Address - Country:US
Practice Address - Phone:262-241-3144
Practice Address - Fax:262-241-3186
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41-156231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41104900Medicaid
WI41104900Medicaid