Provider Demographics
NPI:1235224932
Name:LARSEN, RYAN H (MD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:H
Last Name:LARSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 S MAIN ST STE 210
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-5768
Mailing Address - Country:US
Mailing Address - Phone:435-383-6120
Mailing Address - Fax:435-557-8003
Practice Address - Street 1:258 S MAIN ST STE 210
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-5768
Practice Address - Country:US
Practice Address - Phone:435-383-6120
Practice Address - Fax:435-557-8003
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT175141-1205208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT08582Medicaid
ID340017516Medicaid
UT08582Medicaid
UTD87732Medicare UPIN