Provider Demographics
NPI:1548783707
Name:ELLGEN, DEREK RAY (DPT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:RAY
Last Name:ELLGEN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 396
Mailing Address - Street 2:
Mailing Address - City:GUNNISON
Mailing Address - State:UT
Mailing Address - Zip Code:84634-0396
Mailing Address - Country:US
Mailing Address - Phone:435-528-7575
Mailing Address - Fax:435-528-7000
Practice Address - Street 1:1050 S MEDICAL DR STE A
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:UT
Practice Address - Zip Code:84647-2200
Practice Address - Country:US
Practice Address - Phone:435-462-0178
Practice Address - Fax:435-462-5252
Is Sole Proprietor?:No
Enumeration Date:2017-07-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10448742-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist