Provider Demographics
NPI:1508800145
Name:RYAN, JIMMY LYNN (MD)
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:LYNN
Last Name:RYAN
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:PO BOX 1010
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-1010
Mailing Address - Country:US
Mailing Address - Phone:801-253-3500
Mailing Address - Fax:801-253-5859
Practice Address - Street 1:1288 W 12700 S
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-6794
Practice Address - Country:US
Practice Address - Phone:801-253-3500
Practice Address - Fax:801-253-5859
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT172229-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTQM0000032877OtherALTIUS HEALTH PLANS
UT870641072RY1OtherEDUCATORS MUTUAL
UTPR00710OtherMOLINA HEALTHCARE
UT071262OtherSELECT HEALTH
UT071262OtherSELECT HEALTH
UT01WCHKL16Medicare ID - Type Unspecified