Healthcare Provider Details

I. General information

NPI: 1558247957
Provider Name (Legal Business Name): AUSTIN CLEMETSON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2025
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4155 LEGION LN STE 2
CASPER WY
82609-1945
US

IV. Provider business mailing address

4155 LEGION LN STE 2
CASPER WY
82609-1945
US

V. Phone/Fax

Practice location:
  • Phone: 307-259-0508
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberPT-2548
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: