Provider Demographics
NPI:1710224167
Name:NORDGREN, RYAN WINDER (CRNA)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:WINDER
Last Name:NORDGREN
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 1:1017 CHASE MDWS
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-2930
Mailing Address - Country:US
Mailing Address - Phone:801-633-4702
Mailing Address - Fax:
Practice Address - Street 1:2200 W 21ST ST
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-2011
Practice Address - Country:US
Practice Address - Phone:801-633-4702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-04
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN619284367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered