Provider Demographics
NPI:1265663587
Name:BOULTER, MICHAEL RAYMOND (DPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RAYMOND
Last Name:BOULTER
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:PO BOX 1790
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-1790
Mailing Address - Country:US
Mailing Address - Phone:307-358-9464
Mailing Address - Fax:307-358-9330
Practice Address - Street 1:311 THELMA DR
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-2325
Practice Address - Country:US
Practice Address - Phone:307-234-2662
Practice Address - Fax:307-234-8810
Is Sole Proprietor?:No
Enumeration Date:2009-08-04
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT-1283225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist