Healthcare Provider Details

I. General information

NPI: 1124382577
Provider Name (Legal Business Name): RYAN GRAHAM BUNDENTHAL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2012
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E ROLLINS ST
ORLANDO FL
32803-1248
US

IV. Provider business mailing address

851 TRAFALGAR CT STE 200E
MAITLAND FL
32751-7420
US

V. Phone/Fax

Practice location:
  • Phone: 407-667-0444
  • Fax:
Mailing address:
  • Phone: 407-667-0444
  • Fax: 407-667-4338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number333051
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberEL32193
License Number StateNH
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN9464975
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: