Healthcare Provider Details

I. General information

NPI: 1982934758
Provider Name (Legal Business Name): RAY A ROLLINS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2009
Last Update Date: 12/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 RUTH ST N SUITE 202
SAINT PAUL MN
55119-4323
US

IV. Provider business mailing address

1575 BEAM AVE ANESTHESIA DEPT
SAINT PAUL MN
55109-1126
US

V. Phone/Fax

Practice location:
  • Phone: 651-251-8021
  • Fax: 651-251-8050
Mailing address:
  • Phone: 651-735-0501
  • Fax: 651-735-1870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR1473649
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: