Provider Demographics
NPI:1992880272
Name:HENRY, RYAN LEE (CRNA)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:LEE
Last Name:HENRY
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:PO BOX 3466
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25334-3466
Mailing Address - Country:US
Mailing Address - Phone:304-720-8816
Mailing Address - Fax:904-494-6467
Practice Address - Street 1:2520 VALLEY DR
Practice Address - Street 2:
Practice Address - City:POINT PLEASANT
Practice Address - State:WV
Practice Address - Zip Code:25550-2031
Practice Address - Country:US
Practice Address - Phone:304-720-8816
Practice Address - Fax:904-494-6467
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV38000367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001706470OtherMSBCBS
WV3810000766Medicaid
WV001720988OtherMTSTBC SERVICE ID #
WVP00378293OtherRR MEDICARE
WV0207026000Medicaid
WVDA0096OtherRR MEDICARE
WV3810000766Medicaid
WV8230603Medicare PIN
WV270052997004OtherTRICARE
WV8230601Medicare PIN
WV001720988OtherMTSTBC SERVICE ID #
WV3810000766Medicaid
WV1059862OtherWORKER'S COMP
WV27005299700OtherBRICKSTREET
WV2460484Medicaid
WV1059862OtherBRICKSTREET INDIVIDUAL
WV3810006746Medicaid
WV2513168Medicaid
WV9364011Medicare PIN