=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578092565
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW JAY FUHR PT, DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2017
-----------------------------------------------------
Last Update Date | 02/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1211 S DOUGLAS HWY STE 100
-----------------------------------------------------
City | GILLETTE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-670-9191
-----------------------------------------------------
Fax | 307-670-9193
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1211 S DOUGLAS HWY STE 100
-----------------------------------------------------
City | GILLETTE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82716-4982
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-670-9191
-----------------------------------------------------
Fax | 307-670-9193
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1539
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------