Provider Demographics
NPI:1639794324
Name:ABRAHAM, RYAN (CRNA)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:ABRAHAM
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 1:17989 RESTORATION CIR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-5237
Mailing Address - Country:US
Mailing Address - Phone:321-749-9317
Mailing Address - Fax:
Practice Address - Street 1:500 FISHER ST
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39534-2502
Practice Address - Country:US
Practice Address - Phone:321-749-9317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSABRA-OKEEM6367500000X
FLRN9309082163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine