Healthcare Provider Details

I. General information

NPI: 1457330631
Provider Name (Legal Business Name): RYAN RAYMOND RILEY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2006
Last Update Date: 05/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 NORTH AVE
NORTHFIELD MN
55057-1498
US

IV. Provider business mailing address

2000 NORTH AVE
NORTHFIELD MN
55057-1498
US

V. Phone/Fax

Practice location:
  • Phone: 507-646-1000
  • Fax:
Mailing address:
  • Phone: 507-646-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR 152951-9
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPN3269
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: