Provider Demographics
NPI:1053334730
Name:ANDERSON, RYAN K (DPM)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:K
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:596 W 750 S
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-7268
Mailing Address - Country:US
Mailing Address - Phone:801-292-4425
Mailing Address - Fax:801-397-1938
Practice Address - Street 1:596 W 750 S
Practice Address - Street 2:SUITE 200
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-7268
Practice Address - Country:US
Practice Address - Phone:801-292-4425
Practice Address - Fax:801-397-1938
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT282785-0501213ES0103X
UT46D2116123246Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No246Q00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU91268Medicare UPIN
UTP00066583Medicare PIN
UT005738401Medicare PIN