Provider Demographics
NPI:1487046199
Name:RIALS, TOMMY LAWAYNE (CRNA)
Entity Type:Individual
Prefix:
First Name:TOMMY
Middle Name:LAWAYNE
Last Name:RIALS
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 1:2101 ELM ST N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-2417
Mailing Address - Country:US
Mailing Address - Phone:701-232-3241
Mailing Address - Fax:
Practice Address - Street 1:2101 ELM ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-2417
Practice Address - Country:US
Practice Address - Phone:701-232-3241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-04
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR876982367500000X
NDR53341367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02089876Medicaid
MS396507YPC0Medicare PIN
MS02089876Medicaid