Provider Demographics
NPI:1437179215
Name:GAYNOR, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:GAYNOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6908 N SANTA MONICA BLVD
Mailing Address - Street 2:
Mailing Address - City:FOX POINT
Mailing Address - State:WI
Mailing Address - Zip Code:53217-3942
Mailing Address - Country:US
Mailing Address - Phone:414-352-2082
Mailing Address - Fax:414-352-5279
Practice Address - Street 1:19045 W CAPITOL DR
Practice Address - Street 2:SUITE 101
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-2706
Practice Address - Country:US
Practice Address - Phone:262-790-9800
Practice Address - Fax:262-790-9893
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40466100Medicaid
WI40466100Medicaid