Provider Demographics
NPI:1093730434
Name:RYAN, CRAIG (CRNA)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:
Last Name:RYAN
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 1:6930 E TETON CIR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-0939
Mailing Address - Country:US
Mailing Address - Phone:480-924-7829
Mailing Address - Fax:480-924-7829
Practice Address - Street 1:1301 S CRISMON RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-3767
Practice Address - Country:US
Practice Address - Phone:480-358-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0265367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ79555203Medicaid
AZ118418Medicare PIN
AZWMBFK-75525Medicare PIN
AZ79555203Medicaid