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: 12/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 HEALTH PARK BLVD LIGHTHOUSE ANESTHESIOLOGY CONSULTANTS
ST AUGUSTINE FL
32086-5784
US

IV. Provider business mailing address

PO BOX 3012
ST AUGUSTINE FL
32085-3012
US

V. Phone/Fax

Practice location:
  • Phone: 904-819-4478
  • Fax: 770-237-1124
Mailing address:
  • Phone: 866-480-2246
  • Fax: 770-237-1124

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: