Provider Demographics
NPI:1215039979
Name:RYAN, ROBERT LAWRENCE (CRNA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LAWRENCE
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 1:1856 PECAN DR
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-8023
Mailing Address - Country:US
Mailing Address - Phone:662-429-5909
Mailing Address - Fax:662-349-0677
Practice Address - Street 1:7580 CLARINGTON CV
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-5657
Practice Address - Country:US
Practice Address - Phone:662-349-9136
Practice Address - Fax:662-349-0677
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR691259367500000X
TNAPN0000009584367500000X
ARC00318 CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00122694Medicaid
MS00122694Medicaid