Provider Demographics
NPI:1750316519
Name:ELLSAESSER, RICKY D (CRNA)
Entity Type:Individual
Prefix:MR
First Name:RICKY
Middle Name:D
Last Name:ELLSAESSER
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 32861
Mailing Address - Street 2:ANESTHESIA SERVICES - 5TH FL SURGERY TOWER
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28232-2861
Mailing Address - Country:US
Mailing Address - Phone:704-355-2375
Mailing Address - Fax:
Practice Address - Street 1:1000 BLYTHE BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5812
Practice Address - Country:US
Practice Address - Phone:704-355-2375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0157516367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8051996Medicaid
SCNAN709Medicaid
NC8051996Medicaid