Healthcare Provider Details

I. General information

NPI: 1972103885
Provider Name (Legal Business Name): RYAN JAMES LARSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2020
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 E MAIN ST STE 2
BOZEMAN MT
59715-3823
US

IV. Provider business mailing address

401 S ALABAMA ST STE 10
BUTTE MT
59701-2358
US

V. Phone/Fax

Practice location:
  • Phone: 406-587-8478
  • Fax: 406-582-0730
Mailing address:
  • Phone: 406-782-2278
  • Fax: 406-782-2483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number164888
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number164888
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: