Basic Information
| Provider Information | |||||||||
| NPI: | 1053079103 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARDNER | ||||||||
| FirstName: | MELISSA | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 374 | ||||||||
| Address2: | |||||||||
| City: | RIVERTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825010075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078510859 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1901 HOWELL AVE | ||||||||
| Address2: | |||||||||
| City: | WORLAND | ||||||||
| State: | WY | ||||||||
| PostalCode: | 824013733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073474285 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2021 | ||||||||
| LastUpdateDate: | 12/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA300 | WY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0859 | 05 | WY | MEDICAID |