Provider Demographics
NPI:1780836205
Name:RYAN, KIMBERLY CLAIRE (RN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:CLAIRE
Last Name:RYAN
Suffix:
Gender:F
Credentials:RN
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 FLOOR SURGICAL TOWER
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28232-2861
Mailing Address - Country:US
Mailing Address - Phone:704-355-8983
Mailing Address - Fax:704-355-8994
Practice Address - Street 1:1000 BLYTHE BLVD
Practice Address - Street 2:ANESTHESIA SERVICES-5TH FLOOR SURGICAL TOWER
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5812
Practice Address - Country:US
Practice Address - Phone:704-355-8983
Practice Address - Fax:704-355-8994
Is Sole Proprietor?:No
Enumeration Date:2008-10-15
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC193581367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8053658Medicaid
SCNAN902Medicaid
SCNAN902Medicaid