Healthcare Provider Details

I. General information

NPI: 1205915667
Provider Name (Legal Business Name): RICKY JOE WARREN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 GOODYEAR AVE
GADSDEN AL
35903-1195
US

IV. Provider business mailing address

3875 DOGWOOD DR
HOKES BLUFF AL
35903-7460
US

V. Phone/Fax

Practice location:
  • Phone: 256-494-4000
  • Fax:
Mailing address:
  • Phone: 256-492-2521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1039272
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: