Provider Demographics
NPI:1538186374
Name:PHAN, RUBY S (CRNA)
Entity type:Individual
Prefix:
First Name:RUBY
Middle Name:S
Last Name:PHAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:RUBY
Other - Middle Name:C
Other - Last Name:STA ROMANA
Other - Suffix:V
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:1329 SW 16TH ST RM 2232
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-1128
Mailing Address - Country:US
Mailing Address - Phone:352-733-0485
Mailing Address - Fax:
Practice Address - Street 1:400 N MILLS AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-5722
Practice Address - Country:US
Practice Address - Phone:407-872-2244
Practice Address - Fax:407-926-9173
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3102212367500000X
FLAPRN3102212367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG3562OtherBCBS
FL3063518 00Medicaid