Provider Demographics
NPI:1386639763
Name:FERGUSON, BRADLEY L (MPT)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:L
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 W SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-2283
Mailing Address - Country:US
Mailing Address - Phone:073-709-1753
Mailing Address - Fax:307-370-9177
Practice Address - Street 1:1102 W SPRUCE ST
Practice Address - Street 2:
Practice Address - City:RAWLINS
Practice Address - State:WY
Practice Address - Zip Code:82301-5335
Practice Address - Country:US
Practice Address - Phone:307-370-9175
Practice Address - Fax:307-370-9177
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9632024225100000X
WYPT-17632251X0800X, 2251X0800X
WY1763225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41570000OtherMEDICAID DME
WI40358600Medicaid
5372600001OtherMEDICARE DMEPOS
5372600001OtherMEDICARE DMEPOS