Provider Demographics
NPI:1346567369
Name:RYAN, MARISA ANN (MD)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:ANN
Last Name:RYAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N 300 W STE 401
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3306
Mailing Address - Country:US
Mailing Address - Phone:801-357-7499
Mailing Address - Fax:801-373-5980
Practice Address - Street 1:3000 N TRIUMPH BLVD STE 260
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-4999
Practice Address - Country:US
Practice Address - Phone:801-768-3500
Practice Address - Fax:801-768-3506
Is Sole Proprietor?:No
Enumeration Date:2010-04-29
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD83114207Y00000X
GA88123207Y00000X, 207YX0007X
CT047679149207Y00000X
UT12974559-1205207YP0228X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck