Healthcare Provider Details

I. General information

NPI: 1497864615
Provider Name (Legal Business Name): RYAN A HULZEBOS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 11/27/2023
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7150 CLEARVISTA DR
INDIANAPOLIS IN
46256-1695
US

IV. Provider business mailing address

6626 E 75TH ST SUITE 500
INDIANAPOLIS IN
46250-2805
US

V. Phone/Fax

Practice location:
  • Phone: 317-621-9002
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4770A
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28220828A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: