Basic Information
| Provider Information | |||||||||
| NPI: | 1356417257 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSEN | ||||||||
| FirstName: | RYAN | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11225 | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374012225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238925602 | ||||||||
| FaxNumber: | 4238925838 | ||||||||
| Practice Location | |||||||||
| Address1: | 975 E THIRD ST | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374032147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236028400 | ||||||||
| FaxNumber: | 4236028401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2006 | ||||||||
| LastUpdateDate: | 03/30/2016 | ||||||||
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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 | 163W00000X | RN109710 | TN | N | Nursing Service Providers | Registered Nurse | 367500000X | APN10970 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 8052068 | 05 | NC | MEDICAID | 3633245 | 05 | TN | MEDICAID | 413484745A | 05 | GA | MEDICAID | P00098720 | 01 | TN | RAILROAD MEDICARE | OTHER | 4068615 | 01 | TN | BLUE CROSS BLUE SHIELD TN | OTHER | N348393 | 01 | GA | WELLCARE (GA MEDICAID) | OTHER |