Provider Demographics
NPI:1871618553
Name:RYZNYK, LAURIE R (PA-C)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:R
Last Name:RYZNYK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:R
Other - Last Name:WALTRIP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 W OAK ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-1400
Mailing Address - Country:US
Mailing Address - Phone:618-536-6621
Mailing Address - Fax:
Practice Address - Street 1:305 W JACKSON ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1474
Practice Address - Country:US
Practice Address - Phone:618-453-3777
Practice Address - Fax:618-453-1102
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant