Provider Demographics
NPI:1457330631
Name:RILEY, RYAN RAYMOND (CRNA)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:RAYMOND
Last Name:RILEY
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 1:2000 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057-1498
Mailing Address - Country:US
Mailing Address - Phone:507-646-1000
Mailing Address - Fax:
Practice Address - Street 1:2000 NORTH AVE
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55057-1498
Practice Address - Country:US
Practice Address - Phone:507-646-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 152951-9367500000X
SCAPN3269367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN049059800Medicaid
SCAN1592Medicaid
MN049059800Medicaid
SCQ344911162Medicare PIN