Provider Demographics
NPI:1003122615
Name:FOUNTAIN, JOSHUA J (PTA)
Entity Type:Individual
Prefix:MR
First Name:JOSHUA
Middle Name:J
Last Name:FOUNTAIN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4502 GREENFIELD CT
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-2315
Mailing Address - Country:US
Mailing Address - Phone:307-757-5310
Mailing Address - Fax:
Practice Address - Street 1:6598 BUTTERCUP DR UNIT 1
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:CO
Practice Address - Zip Code:80549
Practice Address - Country:US
Practice Address - Phone:970-699-2260
Practice Address - Fax:970-514-3519
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-20
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPTA0672225200000X
COPTA.0014221225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty