Provider Demographics
NPI:1528533825
Name:WALSH, RYAN MCLEAN (PA-C)
Entity type:Individual
Prefix:MR
First Name:RYAN
Middle Name:MCLEAN
Last Name:WALSH
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 1:4646 S ZENIA MEADOWS CT
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-4117
Mailing Address - Country:US
Mailing Address - Phone:385-775-4405
Mailing Address - Fax:
Practice Address - Street 1:1454 UNIVERSITY VLG
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-3518
Practice Address - Country:US
Practice Address - Phone:385-775-4354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-12
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA64860363A00000X
UT390200000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty