Provider Demographics
NPI:1235197922
Name:VASQUEZ, ELOY A (DPT)
Entity Type:Individual
Prefix:MR
First Name:ELOY
Middle Name:A
Last Name:VASQUEZ
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:453 VANDEHEI AVE
Mailing Address - Street 2:SUITE 130-140
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-6010
Mailing Address - Country:US
Mailing Address - Phone:307-514-5834
Mailing Address - Fax:307-514-5837
Practice Address - Street 1:453 VANDEHEI AVE
Practice Address - Street 2:SUITE 130-140
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-6010
Practice Address - Country:US
Practice Address - Phone:307-514-5834
Practice Address - Fax:307-514-5837
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY229225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY107090800Medicaid
WY107090800Medicaid