Provider Demographics
NPI:1558375006
Name:NELSON, KRISTOPHER S (MPT)
Entity Type:Individual
Prefix:MR
First Name:KRISTOPHER
Middle Name:S
Last Name:NELSON
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 WEST SUNSET DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501
Mailing Address - Country:US
Mailing Address - Phone:307-856-7021
Mailing Address - Fax:307-856-5546
Practice Address - Street 1:2002 WEST SUNSET DR
Practice Address - Street 2:SUITE 1
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501
Practice Address - Country:US
Practice Address - Phone:307-856-7021
Practice Address - Fax:307-856-5546
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT975225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY313876OtherBLUE CROSS BLUE SHIELD
P47453Medicare UPIN
WY313876OtherBLUE CROSS BLUE SHIELD