Healthcare Provider Details

I. General information

NPI: 1881750578
Provider Name (Legal Business Name): RYAN HAL LATIMER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 11/27/2023
Certification Date: 02/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1184 E 80 N
AMERICAN FORK UT
84003-2906
US

IV. Provider business mailing address

1055 N 500 W ATTN: CREDENTIALING
PROVO UT
84604-3305
US

V. Phone/Fax

Practice location:
  • Phone: 801-763-3885
  • Fax: 801-763-3887
Mailing address:
  • Phone: 801-354-8225
  • Fax: 801-418-0941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number6344620-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: