Healthcare Provider Details

I. General information

NPI: 1689847485
Provider Name (Legal Business Name): RYAN GREGORY FIRTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2008
Last Update Date: 11/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 BUENA VISTA DR
LANDER WY
82520-3431
US

IV. Provider business mailing address

745 BUENA VISTA DR
LANDER WY
82520-3431
US

V. Phone/Fax

Practice location:
  • Phone: 307-332-2941
  • Fax: 307-332-1920
Mailing address:
  • Phone: 307-332-2941
  • Fax: 307-332-1920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2008005511
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number8120A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: