Basic Information
Provider Information | |||||||||
NPI: | 1639505779 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GARRITSON | ||||||||
FirstName: | RYAN | ||||||||
MiddleName: | K | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 27128 | ||||||||
Address2: |   | ||||||||
City: | SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 841270128 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8014088700 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 324 E 10TH AVE | ||||||||
Address2: | SUITE 100 | ||||||||
City: | SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 841032853 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8014088700 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2013 | ||||||||
LastUpdateDate: | 04/22/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9107450 | FL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363A00000X | 9372775-1206 | UT | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 009948600 | 05 | FL |   | MEDICAID | P01275770 | 01 | FL | RAILROAD MEDICARE | OTHER |