Healthcare Provider Details

I. General information

NPI: 1780510180
Provider Name (Legal Business Name): ELLIOTT DERONG TAN DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4554 FORESTDALE DR UNIT C16
PARK CITY UT
84098-1392
US

IV. Provider business mailing address

1448 S 600 E
SALT LAKE CITY UT
84105-2052
US

V. Phone/Fax

Practice location:
  • Phone: 435-494-1336
  • Fax:
Mailing address:
  • Phone: 206-953-6096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number14288308-2401
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: