Provider Demographics
NPI:1124538475
Name:NANKERVIS, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:NANKERVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 W JACKSON STREET
Mailing Address - Street 2:DBA SIH MEDICAL GROUP ANESTHESIOLOGY
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-1462
Mailing Address - Country:US
Mailing Address - Phone:618-549-0721
Mailing Address - Fax:618-529-0449
Practice Address - Street 1:405 W JACKSON STREET
Practice Address - Street 2:DBA SIH MEDICAL GROUP ANESTHESIOLOGY
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1462
Practice Address - Country:US
Practice Address - Phone:618-549-0721
Practice Address - Fax:618-529-0449
Is Sole Proprietor?:No
Enumeration Date:2017-10-01
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041404827163W00000X
IL209016792367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214881OtherMULTI SPECIALTY GROUP