Provider Demographics
NPI:1528423365
Name:NUCKOLS, JOHN RYAN (DNP CRNA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:RYAN
Last Name:NUCKOLS
Suffix:
Gender:M
Credentials:DNP CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6020 PORTICO DR APT 1527
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4189
Mailing Address - Country:US
Mailing Address - Phone:806-282-6439
Mailing Address - Fax:
Practice Address - Street 1:6020 PORTICO DR APT 1527
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4189
Practice Address - Country:US
Practice Address - Phone:806-282-6439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX103227367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered