Provider Demographics
NPI:1992809529
Name:ALLEN, MALCOLM S III (CRNA)
Entity type:Individual
Prefix:
First Name:MALCOLM
Middle Name:S
Last Name:ALLEN
Suffix:III
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 N 960 E
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-2936
Mailing Address - Country:US
Mailing Address - Phone:801-756-9919
Mailing Address - Fax:
Practice Address - Street 1:750 W 800 N
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-3660
Practice Address - Country:US
Practice Address - Phone:800-748-4868
Practice Address - Fax:801-733-5618
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT213871-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT107007300107OtherIHC
UT870525882AL2OtherEDUCATORS MUTUAL
UTPRA07051OtherMOLINA
UT75949OtherPEHP
UT190382600OtherUS DEPT OF LABOR
UTQM0000076595OtherALTIUS
UT011517OtherHEALTHY U
UT870525882AL2OtherEDUCATORS MUTUAL
UTR92039Medicare UPIN
UT004930030Medicare ID - Type Unspecified