Healthcare Provider Details

I. General information

NPI: 1033992664
Provider Name (Legal Business Name): RYAN JAMES BANNAN BSN, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2023
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 NEW BERN AVE
RALEIGH NC
27610-1215
US

IV. Provider business mailing address

3022 BRELLON LN
DURHAM NC
27703-3496
US

V. Phone/Fax

Practice location:
  • Phone: 517-599-4862
  • Fax:
Mailing address:
  • Phone: 517-599-4862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number362524
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: