MEDICARE: RYAN SCOTT THOMSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	13386083-6009	UT

General Provider Information

NPI Number	:	1417788639
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN SCOTT THOMSON

Provider Business Mailing Address
First Line	:	1425 S 700 E STE 102
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-2125
Country	:	US
Telephone Number	:	385-300-9090
Fax Number	:

Provider Business Practice Location Address
First Line	:	4516 S 700 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-4192
Country	:	US
Telephone Number	:	385-313-0055
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2024
Last Update Date	:	08/09/2024

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Directions to “ RYAN SCOTT THOMSON ” Practice Location

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