Provider Demographics
NPI:1871880591
Name:VAN RYN, LAURA M (PA-C)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:M
Last Name:VAN RYN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:M
Other - Last Name:OTTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:411 WESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4152
Mailing Address - Country:US
Mailing Address - Phone:715-847-2558
Mailing Address - Fax:715-847-2752
Practice Address - Street 1:411 WESTWOOD DR
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4152
Practice Address - Country:US
Practice Address - Phone:715-847-2558
Practice Address - Fax:715-847-2752
Is Sole Proprietor?:No
Enumeration Date:2011-07-01
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2772-023363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant