Basic Information
| Provider Information | |||||||||
| NPI: | 1245312552 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCDONALD | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2420 S UNION AVE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984051323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535032598 | ||||||||
| FaxNumber: | 2534040506 | ||||||||
| Practice Location | |||||||||
| Address1: | 3209 S 23RD ST | ||||||||
| Address2: | SUITE 340 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984051602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532725127 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 01/05/2017 | ||||||||
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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 | AP30007531 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | G8862912 | 01 | WA | MDCR PTAN (P) | OTHER | 9651118 | 05 | WA | MEDICAID | G8914633 | 01 | WA | MDCR PTAN (K) | OTHER |