Provider Demographics
NPI:1215945498
Name:NELSON, RYAN WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:WILLIAM
Last Name:NELSON
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 1:3340 NORTH CENTER ST #800
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-7406
Mailing Address - Country:US
Mailing Address - Phone:801-990-1911
Mailing Address - Fax:801-990-1912
Practice Address - Street 1:5121 S COTTONWOOD STREET
Practice Address - Street 2:INTERMOUNTAIN MEDICAL CENTER
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84157
Practice Address - Country:US
Practice Address - Phone:801-507-5248
Practice Address - Fax:801-733-5618
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5198130-1205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY121125100Medicaid
UT870545614RYNOtherEDUCATORS MUTUAL
UT1502954OtherUMWA
UTTPRA11411OtherMOLINA
UT2090168OtherUNITED HEALTHCARE
ID807171300Medicaid
UTQM0000075886OtherALTIUS
NV100506347Medicaid
UT51981301200001OtherBLUE CROSS BLUE SHIELD
AZ941387Medicaid
UT83768OtherPEHP
UT84645OtherHEALTHY U
UT902602OtherDESERET MUTUAL
UT107037815101OtherIHC
UT51981301200001OtherBLUE CROSS BLUE SHIELD
UT83768OtherPEHP
UT870545614RYNOtherEDUCATORS MUTUAL