Healthcare Provider Details

I. General information

NPI: 1619171378
Provider Name (Legal Business Name): MEREK C DEACON P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 N 4TH ST STE 101
LARAMIE WY
82072-2091
US

IV. Provider business mailing address

PO BOX 1146
LARAMIE WY
82073-1146
US

V. Phone/Fax

Practice location:
  • Phone: 307-745-5434
  • Fax: 307-745-5484
Mailing address:
  • Phone: 307-745-5434
  • Fax: 307-745-5484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1098
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: