Basic Information
| Provider Information | |||||||||
| NPI: | 1982994844 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BARRETT | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 360 E MALLARD DR | ||||||||
| Address2: | STE 110 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837063945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083368700 | ||||||||
| FaxNumber: | 2084260902 | ||||||||
| Practice Location | |||||||||
| Address1: | 360 E MALLARD DR | ||||||||
| Address2: | STE 110 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837063945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083368700 | ||||||||
| FaxNumber: | 2084260902 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2011 | ||||||||
| LastUpdateDate: | 10/14/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | M-13360 | ID | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 805858400 | 05 | ID | MEDICAID |