Provider Demographics
NPI:1154323020
Name:MALAN, TRACY L (RPT)
Entity Type:Individual
Prefix:MR
First Name:TRACY
Middle Name:L
Last Name:MALAN
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 MELISSA AVE
Mailing Address - Street 2:STE B
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-3002
Mailing Address - Country:US
Mailing Address - Phone:760-256-1888
Mailing Address - Fax:760-256-2893
Practice Address - Street 1:525 MELISSA AVE
Practice Address - Street 2:STE B
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-3002
Practice Address - Country:US
Practice Address - Phone:760-256-1888
Practice Address - Fax:760-256-2893
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2007-08-15
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-06
Provider Licenses
StateLicense IDTaxonomies
CAPT12940225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist