Provider Demographics
NPI:1316551633
Name:KNUDSON, KEITH RYAN (DPT)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:RYAN
Last Name:KNUDSON
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 1:1560 W COLT DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-9108
Mailing Address - Country:US
Mailing Address - Phone:760-415-0605
Mailing Address - Fax:
Practice Address - Street 1:1230 NORTH FALL CREEK RD
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:WY
Practice Address - Zip Code:83014
Practice Address - Country:US
Practice Address - Phone:307-699-7667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-03
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT-1991225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist