=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558247957
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AUSTIN CLEMETSON DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2025
-----------------------------------------------------
Last Update Date | 08/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4155 LEGION LN STE 2
-----------------------------------------------------
City | CASPER
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82609-1945
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-259-0508
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4155 LEGION LN STE 2
-----------------------------------------------------
City | CASPER
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82609-1945
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251S0007X
-----------------------------------------------------
Taxonomy Name | Sports Physical Therapist
-----------------------------------------------------
License Number | PT-2548
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------