Provider Demographics
NPI:1578633285
Name:RYAN, LESLIE JO (PA)
Entity type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:JO
Last Name:RYAN
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Gender:F
Credentials:PA
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Mailing Address - Street 1:2799 WEST GRAND BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202
Mailing Address - Country:US
Mailing Address - Phone:313-916-9181
Mailing Address - Fax:313-916-5960
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:313-916-9181
Practice Address - Fax:313-916-5960
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
MI5601003274363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical