Healthcare Provider Details

I. General information

NPI: 1235854738
Provider Name (Legal Business Name): RYAN RUSSELL FISTE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2022
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18101 PRINCE PHILIP DR # MD
OLNEY MD
20832-1514
US

IV. Provider business mailing address

6067 FLAGSTONE CT
FREDERICK MD
21701-5846
US

V. Phone/Fax

Practice location:
  • Phone: 130-177-4888
  • Fax:
Mailing address:
  • Phone: 443-812-0095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR223260
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberR223260
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: