1568140143 NPI number — MONTANA RYAN BETTS CRNA

Table of content: MONTANA RYAN BETTS CRNA (NPI 1568140143)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568140143 NPI number — MONTANA RYAN BETTS CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BETTS
Provider First Name:
MONTANA
Provider Middle Name:
RYAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568140143
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/21/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1940 IVY WOOD CV
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLLIERVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38017-8742
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-919-3799
Provider Business Mailing Address Fax Number:
901-287-5102

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ULPS
Provider Second Line Business Practice Location Address:
850 POPLAR AVE, BUILDING 2
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-287-5218
Provider Business Practice Location Address Fax Number:
901-287-5102
Provider Enumeration Date:
07/05/2023

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  34177 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)