Provider Demographics
NPI:1306376975
Name:HASTERT, NICHOLAS HENRY (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:HENRY
Last Name:HASTERT
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 1:210 SUMMERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:GREEN RIVER
Mailing Address - State:WY
Mailing Address - Zip Code:82935-5454
Mailing Address - Country:US
Mailing Address - Phone:307-871-4922
Mailing Address - Fax:
Practice Address - Street 1:330 UPLAND WAY
Practice Address - Street 2:
Practice Address - City:GREEN RIVER
Practice Address - State:WY
Practice Address - Zip Code:82935
Practice Address - Country:US
Practice Address - Phone:307-875-4654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1716225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist