Provider Demographics
NPI:1083269013
Name:WAN, HO MAN HOMAN (PT, DPT, ATC)
Entity type:Individual
Prefix:
First Name:HO MAN HOMAN
Middle Name:
Last Name:WAN
Suffix:
Gender:M
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:JEREMY
Other - Middle Name:
Other - Last Name:WAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT, DPT, ATC
Mailing Address - Street 1:346 W INAUGURATION RD
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-6819
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:346 W INAUGURATION RD
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-6819
Practice Address - Country:US
Practice Address - Phone:208-776-0247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-06
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
UT13972367-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer