Provider Demographics
NPI:1306836242
Name:DEVILLE, RONALD G (CRNA)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:G
Last Name:DEVILLE
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 1:10140 THORNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-7628
Mailing Address - Country:US
Mailing Address - Phone:318-798-0191
Mailing Address - Fax:318-798-0191
Practice Address - Street 1:8001 YOUREE DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-2302
Practice Address - Country:US
Practice Address - Phone:318-212-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-23
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN044438367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1399388Medicaid
LA430067419Medicare PIN
LA1399388Medicaid