Provider Demographics
NPI:1508072885
Name:EZZELL, TRENT M (PT)
Entity Type:Individual
Prefix:
First Name:TRENT
Middle Name:M
Last Name:EZZELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 N MAIN ST
Mailing Address - Street 2:UNIT # 18
Mailing Address - City:GUNNISON
Mailing Address - State:CO
Mailing Address - Zip Code:81230-2412
Mailing Address - Country:US
Mailing Address - Phone:970-641-3298
Mailing Address - Fax:970-641-7369
Practice Address - Street 1:718 N MAIN ST
Practice Address - Street 2:UNIT # 18
Practice Address - City:GUNNISON
Practice Address - State:CO
Practice Address - Zip Code:81230-2412
Practice Address - Country:US
Practice Address - Phone:970-641-3298
Practice Address - Fax:970-641-7369
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9752225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8696B9Medicare ID - Type UnspecifiedTRAILBLAZER HEALTH