Healthcare Provider Details

I. General information

NPI: 1700237278
Provider Name (Legal Business Name): RYAN K ANDERSON D P M P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2016
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MILLS AVE STE 100
LAS VEGAS NM
87701-4169
US

IV. Provider business mailing address

105 MILLS AVE STE 100
LAS VEGAS NM
87701-4169
US

V. Phone/Fax

Practice location:
  • Phone: 505-425-3569
  • Fax: 505-434-0042
Mailing address:
  • Phone: 505-425-3569
  • Fax: 505-434-0042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: RYAN K ANDERSON
Title or Position: OWNER
Credential: DPM
Phone: 801-292-4425