Provider Demographics
NPI:1053494948
Name:BLEDSOE, THOMAS JAMES (MPT)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:JAMES
Last Name:BLEDSOE
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 20970
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82003-7020
Mailing Address - Country:US
Mailing Address - Phone:307-996-4777
Mailing Address - Fax:307-773-8013
Practice Address - Street 1:4017 RAWLINS ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-1800
Practice Address - Country:US
Practice Address - Phone:307-635-2562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYWY1056225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY119304000Medicaid
WY312262OtherBLUE CROSS/BLUE SHIELD
WYP00068933OtherRR MEDICARE
WY312262OtherBLUE CROSS/BLUE SHIELD
WY9888Medicare ID - Type Unspecified