Basic Information
| Provider Information | |||||||||
| NPI: | 1346567369 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | MARISA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N 300 W STE 401 | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013577499 | ||||||||
| FaxNumber: | 8013735980 | ||||||||
| Practice Location | |||||||||
| Address1: | 3000 N TRIUMPH BLVD STE 260 | ||||||||
| Address2: | |||||||||
| City: | LEHI | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840434999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017683500 | ||||||||
| FaxNumber: | 8017683506 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2010 | ||||||||
| LastUpdateDate: | 08/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | D83114 | MD | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 88123 | GA | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 047679149 | CT | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207YP0228X | 12974559-1205 | UT | N | Allopathic & Osteopathic Physicians | Otolaryngology | Pediatric Otolaryngology | 207YX0007X | 88123 | GA | N | Allopathic & Osteopathic Physicians | Otolaryngology | Plastic Surgery within the Head & Neck | 207Y00000X | 12974559-1205 | UT | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
No ID Information.