Healthcare Provider Details

I. General information

NPI: 1568140143
Provider Name (Legal Business Name): MONTANA RYAN BETTS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2023
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ULPS 850 POPLAR AVE, BUILDING 2
MEMPHIS TN
38105
US

IV. Provider business mailing address

1940 IVY WOOD CV
COLLIERVILLE TN
38017-8742
US

V. Phone/Fax

Practice location:
  • Phone: 901-287-5218
  • Fax: 901-287-5102
Mailing address:
  • Phone: 870-919-3799
  • Fax: 901-287-5102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number34177
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: