Basic Information
| Provider Information | |||||||||
| NPI: | 1053872416 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | JOEL | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2205 S BRAEMAR DR | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571054123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053599925 | ||||||||
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| Practice Location | |||||||||
| Address1: | ADDRESS: 101 TOWER RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | DAKOTA DUNES | ||||||||
| State: | SD | ||||||||
| PostalCode: | 57049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6052323332 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2019 | ||||||||
| LastUpdateDate: | 03/28/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | CR001018 | SD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | R036782 | 01 | SD | RN LICENSE | OTHER |