Healthcare Provider Details

I. General information

NPI: 1508855982
Provider Name (Legal Business Name): ROBERT B RYDER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 10/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 CHRISTY DR
JEFFERSON CITY MO
65101-2853
US

IV. Provider business mailing address

1445 CHRISTY DR
JEFFERSON CITY MO
65101-2853
US

V. Phone/Fax

Practice location:
  • Phone: 573-636-3483
  • Fax: 573-636-5315
Mailing address:
  • Phone: 573-636-3483
  • Fax: 573-636-5315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number095593
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: