Provider Demographics
NPI:1497982797
Name:VANNATTA, MICHAEL (DPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:VANNATTA
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 160010
Mailing Address - Street 2:
Mailing Address - City:BIG SKY
Mailing Address - State:MT
Mailing Address - Zip Code:59716-0010
Mailing Address - Country:US
Mailing Address - Phone:406-522-7488
Mailing Address - Fax:406-522-7487
Practice Address - Street 1:135 PROSPECT LOOP
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-5985
Practice Address - Country:US
Practice Address - Phone:406-585-9044
Practice Address - Fax:406-585-9220
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2524225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1497982797Medicaid
IDP0080244OtherRR MEDICARE
ID1497982797-001Medicaid
ID1497982797-002Medicaid
ID1497982797-000Medicaid
IDP0080244OtherRR MEDICARE