Healthcare Provider Details

I. General information

NPI: 1245486307
Provider Name (Legal Business Name): RYAN THOMAS PETERSON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2008
Last Update Date: 09/25/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2019 E RIVERSIDE DR STE A101
ST GEORGE UT
84790-8147
US

IV. Provider business mailing address

9980 S 300 W STE 300
ST GEORGE UT
84790
US

V. Phone/Fax

Practice location:
  • Phone: 801-253-6888
  • Fax: 385-900-5928
Mailing address:
  • Phone: 801-273-0001
  • Fax: 385-900-5928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number1104
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number7930013-0501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: