Provider Demographics
NPI:1639505779
Name:GARRITSON, RYAN K (PA-C)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:K
Last Name:GARRITSON
Suffix:
Gender:M
Credentials:PA-C
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 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-408-8700
Mailing Address - Fax:
Practice Address - Street 1:324 E 10TH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84103-2853
Practice Address - Country:US
Practice Address - Phone:801-408-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-20
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107450363A00000X
UT9372775-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009948600Medicaid
FLP01275770OtherRAILROAD MEDICARE
FLHP073ZMedicare PIN