Healthcare Provider Details

I. General information

NPI: 1245243724
Provider Name (Legal Business Name): BRIAN LAVERN RYDER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9205 SW BARNES RD
PORTLAND OR
97225-6603
US

IV. Provider business mailing address

12535 NW BRIMPTON CT
PORTLAND OR
97229-9310
US

V. Phone/Fax

Practice location:
  • Phone: 503-216-1234
  • Fax:
Mailing address:
  • Phone: 503-645-5483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: