=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235854738
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN RUSSELL FISTE RN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2022
-----------------------------------------------------
Last Update Date | 07/07/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18101 PRINCE PHILIP DR # MD
-----------------------------------------------------
City | OLNEY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20832-1514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 130-177-4888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6067 FLAGSTONE CT
-----------------------------------------------------
City | FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21701-5846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-812-0095
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | R223260
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine Registered Nurse
-----------------------------------------------------
License Number | R223260
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------