Healthcare Provider Details

I. General information

NPI: 1962292672
Provider Name (Legal Business Name): JOSHUA HAYDEN WILLOUGHBY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2025
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
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 113
BIG PINEY WY
83113-0113
US

V. Phone/Fax

Practice location:
  • Phone: 307-745-5434
  • Fax:
Mailing address:
  • Phone: 307-260-3117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA1144
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: