=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366328726
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN MACKAY AUSTIN MSN, APRN, FNP-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2025
-----------------------------------------------------
Last Update Date | 10/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1515 N 400 E STE 104
-----------------------------------------------------
City | NORTH LOGAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84341-7595
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-755-6061
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 S 11TH AVE STE 400
-----------------------------------------------------
City | POCATELLO
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83201-4880
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-232-7862
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 11098002-4405
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------