Provider Demographics
NPI:1073795985
Name:GOLOB, RYAN C (CRNA)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:C
Last Name:GOLOB
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 IRONWOOD PL STE B
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2662
Mailing Address - Country:US
Mailing Address - Phone:208-765-8585
Mailing Address - Fax:
Practice Address - Street 1:2003 KOOTENAI HEALTH WAY
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-6051
Practice Address - Country:US
Practice Address - Phone:208-666-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-03
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO160305367500000X
IDRNA-866A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO160305OtherCOLORADO LICENSE
IDRNA-866AOtherIDAHO LICENSE