Healthcare Provider Details

I. General information

NPI: 1508800145
Provider Name (Legal Business Name): JIMMY LYNN RYAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 02/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1288 W 12700 S
RIVERTON UT
84065-6794
US

IV. Provider business mailing address

PO BOX 1010
RIVERTON UT
84065-1010
US

V. Phone/Fax

Practice location:
  • Phone: 801-253-3500
  • Fax: 801-253-5859
Mailing address:
  • Phone: 801-253-3500
  • Fax: 801-253-5859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number172229-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: