Provider Demographics
NPI:1699446302
Name:MARCIANO, MATTHEW (DPT, PT, CSCS)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:MARCIANO
Suffix:
Gender:M
Credentials:DPT, PT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5388 W ORION HILLS CV
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84081-3971
Mailing Address - Country:US
Mailing Address - Phone:773-425-2772
Mailing Address - Fax:
Practice Address - Street 1:974 W 14420 S STE 5
Practice Address - Street 2:
Practice Address - City:BLUFFDALE
Practice Address - State:UT
Practice Address - Zip Code:84065-1630
Practice Address - Country:US
Practice Address - Phone:773-425-2772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11793400-24012251S0007X, 2251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic