Provider Demographics
NPI:1619272788
Name:LUELLEN, RALPH L III (CRNA)
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:L
Last Name:LUELLEN
Suffix:III
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 1:1373 E STATE ROAD 62
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-7328
Mailing Address - Country:US
Mailing Address - Phone:812-801-0800
Mailing Address - Fax:
Practice Address - Street 1:500 SW RAMSEY AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5554
Practice Address - Country:US
Practice Address - Phone:541-474-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-20
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60203707367500000X
OR201402159CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN412840154OtherMEDICARE
KY7100818350Medicaid
IN300061265Medicaid