Provider Demographics
NPI:1861878522
Name:ELLIS, RYAN (CRNA)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4511 BARCELONA CIR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-2892
Mailing Address - Country:US
Mailing Address - Phone:801-520-1543
Mailing Address - Fax:
Practice Address - Street 1:4511 BARCELONA CIR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-2892
Practice Address - Country:US
Practice Address - Phone:801-520-1543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-05
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6220295-3102367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered