Healthcare Provider Details

I. General information

NPI: 1528533825
Provider Name (Legal Business Name): RYAN MCLEAN WALSH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2018
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1454 UNIVERSITY VLG
SALT LAKE CITY UT
84108-3518
US

IV. Provider business mailing address

4646 S ZENIA MEADOWS CT
SALT LAKE CITY UT
84107-4117
US

V. Phone/Fax

Practice location:
  • Phone: 385-775-4354
  • Fax:
Mailing address:
  • Phone: 385-775-4405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA64860
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: