Provider Demographics
NPI:1376603290
Name:RYAN, JESSE LYNN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:LYNN
Last Name:RYAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
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Mailing Address - Street 1:4282 DEERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-4224
Mailing Address - Country:US
Mailing Address - Phone:706-597-5239
Mailing Address - Fax:706-597-5141
Practice Address - Street 1:521 HILL STREET, SW
Practice Address - Street 2:
Practice Address - City:THOMSON
Practice Address - State:GA
Practice Address - Zip Code:30824-2118
Practice Address - Country:US
Practice Address - Phone:706-597-5239
Practice Address - Fax:706-597-5141
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GAR074053367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000519384EMedicaid
GA43ZCBFHOtherMEDICARE