Provider Demographics
NPI:1124382577
Name:BUNDENTHAL, RYAN GRAHAM (CRNA)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:GRAHAM
Last Name:BUNDENTHAL
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 1:851 TRAFALGAR CT STE 200E
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7420
Mailing Address - Country:US
Mailing Address - Phone:407-667-0444
Mailing Address - Fax:407-667-4338
Practice Address - Street 1:601 E ROLLINS ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1248
Practice Address - Country:US
Practice Address - Phone:407-667-0444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-30
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH333051163WC0200X
FLAPRN9464975367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine