Provider Demographics
NPI:1407507056
Name:GUNDRUM, RYAN (CRNA)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:GUNDRUM
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 840842
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0842
Mailing Address - Country:US
Mailing Address - Phone:206-625-0578
Mailing Address - Fax:206-625-9184
Practice Address - Street 1:600 BROADWAY STE 270
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-5392
Practice Address - Country:US
Practice Address - Phone:206-625-0578
Practice Address - Fax:206-625-9184
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-14
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL139454367500000X
WAAP61267515367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty