Provider Demographics
NPI:1114110079
Name:MALAN, VERNON R (PT)
Entity type:Individual
Prefix:
First Name:VERNON
Middle Name:R
Last Name:MALAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2380 N 400 E
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-1749
Mailing Address - Country:US
Mailing Address - Phone:435-713-9700
Mailing Address - Fax:435-753-8005
Practice Address - Street 1:1950 S HIGHWAY 89
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:UT
Practice Address - Zip Code:84302-4119
Practice Address - Country:US
Practice Address - Phone:435-723-1902
Practice Address - Fax:435-723-1908
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4974591-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD4976Medicaid