Healthcare Provider Details

I. General information

NPI: 1467685149
Provider Name (Legal Business Name): RYAN E WIGHT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2009
Last Update Date: 12/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 S CRISMON RD
MESA AZ
85209-3767
US

IV. Provider business mailing address

129 W LAKE MEAD PKWY #B-18
HENDERSON NV
89015-7055
US

V. Phone/Fax

Practice location:
  • Phone: 480-358-6100
  • Fax:
Mailing address:
  • Phone: 702-564-4440
  • Fax: 702-558-1522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA0742
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: