Healthcare Provider Details

I. General information

NPI: 1992809529
Provider Name (Legal Business Name): MALCOLM S ALLEN III CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 W 800 N
OREM UT
84057-3660
US

IV. Provider business mailing address

46 N 960 E
AMERICAN FORK UT
84003-2936
US

V. Phone/Fax

Practice location:
  • Phone: 800-748-4868
  • Fax: 801-733-5618
Mailing address:
  • Phone: 801-756-9919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number213871-4406
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: