Provider Demographics
NPI:1093115602
Name:KIRVEN, IAN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:KIRVEN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1156 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-3055
Mailing Address - Country:US
Mailing Address - Phone:509-847-4303
Mailing Address - Fax:
Practice Address - Street 1:1156 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-3055
Practice Address - Country:US
Practice Address - Phone:307-763-4556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-02
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT-1545225100000X
COPTL.0012650225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist