Provider Demographics
NPI:1740390988
Name:COLVIN, ROGER LYNN (PT)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:LYNN
Last Name:COLVIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 MEDICAL DR STE U4
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-4714
Mailing Address - Country:US
Mailing Address - Phone:435-723-6487
Mailing Address - Fax:435-723-6490
Practice Address - Street 1:990 MEDICAL DR STE U4
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-4714
Practice Address - Country:US
Practice Address - Phone:435-723-6487
Practice Address - Fax:435-723-6490
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT114380-2401225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870375865000Medicaid