Healthcare Provider Details

I. General information

NPI: 1811281801
Provider Name (Legal Business Name): MATTHEW RYAN BISHOP CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 05/05/2020
Certification Date: 05/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 YORK ST
NEW HAVEN CT
06510-3220
US

IV. Provider business mailing address

333 CEDAR ST TMP3
NEW HAVEN CT
06510
US

V. Phone/Fax

Practice location:
  • Phone: 203-785-2802
  • Fax: 203-785-6664
Mailing address:
  • Phone: 203-785-2802
  • Fax: 203-785-6664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number079125
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4800
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: