Provider Demographics
NPI:1851055214
Name:MALAGON, ANDREA
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:MALAGON
Suffix:
Gender:F
Credentials:
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 2019
Mailing Address - Street 2:
Mailing Address - City:GYPSUM
Mailing Address - State:CO
Mailing Address - Zip Code:81637-2019
Mailing Address - Country:US
Mailing Address - Phone:970-376-1266
Mailing Address - Fax:
Practice Address - Street 1:180 S FRONTAGE RD W
Practice Address - Street 2:
Practice Address - City:VAIL
Practice Address - State:CO
Practice Address - Zip Code:81657
Practice Address - Country:US
Practice Address - Phone:970-476-1225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-22
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.00177122251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty