MEDICARE: JOHN RYAN NUCKOLS DNP CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	103227	TX

General Provider Information

NPI Number	:	1528423365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN RYAN NUCKOLS DNP CRNA

Provider Business Mailing Address
First Line	:	6020 PORTICO DR APT 1527
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-4189
Country	:	US
Telephone Number	:	806-282-6439
Fax Number	:

Provider Business Practice Location Address
First Line	:	6020 PORTICO DR APT 1527
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-4189
Country	:	US
Telephone Number	:	806-282-6439
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/21/2015
Last Update Date	:	12/21/2015

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