Healthcare Provider Details

I. General information

NPI: 1356887194
Provider Name (Legal Business Name): NATHAN MICHAEL EVERETT PT, DPT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2017
Last Update Date: 11/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 E 19TH ST
CHEYENNE WY
82001-4643
US

IV. Provider business mailing address

433 E 19TH ST
CHEYENNE WY
82001-4643
US

V. Phone/Fax

Practice location:
  • Phone: 307-222-8993
  • Fax: 307-222-5758
Mailing address:
  • Phone: 307-222-8993
  • Fax: 307-222-5758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT1679
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: