Basic Information
| Provider Information | |||||||||
| NPI: | 1609830991 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENRICKSON | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 751 S BASCOM AVE | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951282604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4088855000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 751 S BASCOM AVE | ||||||||
| Address2: | ANESHESIOLOGY DEPARTMENT | ||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951282604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4088855745 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 09/12/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 286590 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | RN286590 | 05 | CA | MEDICAID |