Basic Information
| Provider Information | |||||||||
| NPI: | 1326784091 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GULAN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2965 E TARPON DR STE 150 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836429007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082879420 | ||||||||
| FaxNumber: | 2082879426 | ||||||||
| Practice Location | |||||||||
| Address1: | 1628 W 11010 S STE 101 | ||||||||
| Address2: | |||||||||
| City: | SOUTH JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840951278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016131890 | ||||||||
| FaxNumber: | 8016132909 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2022 | ||||||||
| LastUpdateDate: | 08/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.