Basic Information
| Provider Information | |||||||||
| NPI: | 1871106518 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANN | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | LUKE | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2120 BINFORD ST APT 302 | ||||||||
| Address2: | |||||||||
| City: | LARAMIE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820725380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077611661 | ||||||||
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| Practice Location | |||||||||
| Address1: | 503 S 18TH ST | ||||||||
| Address2: | |||||||||
| City: | LARAMIE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820704303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077423728 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2020 | ||||||||
| LastUpdateDate: | 08/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA-1022 | WY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.