Healthcare Provider Details

I. General information

NPI: 1285164236
Provider Name (Legal Business Name): RYAN COCHRANE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 02/07/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75TH MEDICAL GROUP 7321 BALMER STREET BUILDING 570
HILL AFB UT
84056
US

IV. Provider business mailing address

75TH MEDICAL GROUP 7321 BALMER STREET BUILDING 570
HILL AFB UT
84056
US

V. Phone/Fax

Practice location:
  • Phone: 801-777-7909
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number317986-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number317986-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: