Healthcare Provider Details

I. General information

NPI: 1962244624
Provider Name (Legal Business Name): GRAYSON TYLER STOUT DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2024
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2270 FORD PKWY STE 200
SAINT PAUL MN
55116-3412
US

IV. Provider business mailing address

24451 INWOOD AVE N
FOREST LAKE MN
55025-8375
US

V. Phone/Fax

Practice location:
  • Phone: 612-672-7100
  • Fax:
Mailing address:
  • Phone: 651-325-7463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number13531
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: