Provider Demographics
NPI:1508868100
Name:WANBAUGH, MICHAEL S (MPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:WANBAUGH
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 1:4140 CENTENNIAL HILLS BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-3265
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4070 PLAZA DR STE 107
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82604-4296
Practice Address - Country:US
Practice Address - Phone:307-472-8871
Practice Address - Fax:307-235-6262
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT-506225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY120359200Medicaid
P00208956OtherRR MEDICARE
WY313189OtherBCBS