Provider Demographics
NPI:1538211206
Name:RYAN, JACOB D (CRNA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:D
Last Name:RYAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 W MCNEESE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-5547
Mailing Address - Country:US
Mailing Address - Phone:337-478-0511
Mailing Address - Fax:337-478-5660
Practice Address - Street 1:424 W MCNEESE ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-5547
Practice Address - Country:US
Practice Address - Phone:337-478-0511
Practice Address - Fax:337-478-5660
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN075556367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA391870ZMJFOtherMEDICARE PTAN
LA1438057Medicaid