Provider Demographics
NPI:1538510573
Name:WAHLSTROM, LUKE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:LUKE
Middle Name:
Last Name:WAHLSTROM
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 BUFFALO RUN RD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-2437
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5171 CUB LAKE RD
Practice Address - Street 2:SUITE C310
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7888
Practice Address - Country:US
Practice Address - Phone:928-537-0248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-30
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12316225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist