Provider Demographics
NPI:1366444028
Name:FUENTES, RUBEN (CRNA)
Entity Type:Individual
Prefix:
First Name:RUBEN
Middle Name:
Last Name:FUENTES
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:PO BOX 1070
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37605-1070
Mailing Address - Country:US
Mailing Address - Phone:423-283-0776
Mailing Address - Fax:423-283-0549
Practice Address - Street 1:1111 SUNSET DR
Practice Address - Street 2:SUITE 4
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-3615
Practice Address - Country:US
Practice Address - Phone:423-283-0776
Practice Address - Fax:423-283-0549
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000052244367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3605162Medicaid
TN3605162Medicaid