Healthcare Provider Details

I. General information

NPI: 1205010394
Provider Name (Legal Business Name): RYAN ALAN RUTLEDGE CRNA, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/25/2007
Last Update Date: 09/20/2026
Certification Date: 09/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 44008
JACKSONVILLE FL
32231-4008
US

IV. Provider business mailing address

PO BOX 44008
JACKSONVILLE FL
32231-4008
US

V. Phone/Fax

Practice location:
  • Phone: 904-244-6565
  • Fax: 904-244-3437
Mailing address:
  • Phone: 904-244-6565
  • Fax: 904-244-3437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3056702
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: