Provider Demographics
NPI:1619292745
Name:BYRGE, NICKOLAS RAY (MD)
Entity Type:Individual
Prefix:
First Name:NICKOLAS
Middle Name:RAY
Last Name:BYRGE
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 1:5169 S COTTONWOOD ST STE 410
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-6769
Mailing Address - Country:US
Mailing Address - Phone:801-507-1600
Mailing Address - Fax:
Practice Address - Street 1:5169 S COTTONWOOD ST STE 410
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6769
Practice Address - Country:US
Practice Address - Phone:801-507-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-31
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8141184-1205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery