Provider Demographics
NPI:1487197125
Name:MALONE, ISAAC JOHN (PT, DPT)
Entity type:Individual
Prefix:
First Name:ISAAC
Middle Name:JOHN
Last Name:MALONE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 N GATEWAY DR STE 160
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9882
Mailing Address - Country:US
Mailing Address - Phone:435-799-3111
Mailing Address - Fax:
Practice Address - Street 1:1615 CURLEW DR
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-4718
Practice Address - Country:US
Practice Address - Phone:208-516-1204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-29
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
UT225100000X
IDPT-8842225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No172V00000XOther Service ProvidersCommunity Health Worker