Provider Demographics
NPI:1770039356
Name:WHITE, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 E TABERNACLE ST STE 104
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-2951
Mailing Address - Country:US
Mailing Address - Phone:435-625-1159
Mailing Address - Fax:435-319-8690
Practice Address - Street 1:249 E TABERNACLE ST STE 104
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-2951
Practice Address - Country:US
Practice Address - Phone:435-625-1159
Practice Address - Fax:435-319-8690
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7996304-4405363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily