Provider Demographics
NPI:1003705807
Name:RYAN, MICHAELA THERESE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MICHAELA
Middle Name:THERESE
Last Name:RYAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:MICHAELA
Other - Middle Name:THERESE
Other - Last Name:QUAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:940 MONROE AVE NW UNIT 428
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1487
Mailing Address - Country:US
Mailing Address - Phone:616-498-8433
Mailing Address - Fax:
Practice Address - Street 1:905 E COLBY ST STE 120
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:MI
Practice Address - Zip Code:49461-1262
Practice Address - Country:US
Practice Address - Phone:231-672-8050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-30
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601013044363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant