Provider Demographics
NPI:1992227789
Name:CARLSON, RYAN SCOTT (NP-C)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:SCOTT
Last Name:CARLSON
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:MEDICAL ADMINISTRATION
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9606
Mailing Address - Country:US
Mailing Address - Phone:616-252-3900
Mailing Address - Fax:616-252-3920
Practice Address - Street 1:11160 W J PRESLEY PARKWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:ALLENDALE
Practice Address - State:MI
Practice Address - Zip Code:49401
Practice Address - Country:US
Practice Address - Phone:616-252-3900
Practice Address - Fax:616-252-3920
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704282755363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily