Provider Demographics
NPI:1245486307
Name:PETERSON, RYAN THOMAS (DPM)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:THOMAS
Last Name:PETERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9980 S 300 W
Mailing Address - Street 2:STE 300
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790
Mailing Address - Country:US
Mailing Address - Phone:801-273-0001
Mailing Address - Fax:385-900-5928
Practice Address - Street 1:2019 E RIVERSIDE DR STE A101
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-8147
Practice Address - Country:US
Practice Address - Phone:801-253-6888
Practice Address - Fax:385-900-5928
Is Sole Proprietor?:No
Enumeration Date:2008-08-08
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1104213ES0103X
UT7930013-0501213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1245486307Medicaid
NV1245486307Medicaid