Provider Demographics
NPI:1619637279
Name:SAMELSON, MICHAEL PARK (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PARK
Last Name:SAMELSON
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 1:11169 E I25 FRONTAGE RD STE C
Mailing Address - Street 2:
Mailing Address - City:FIRESTONE
Mailing Address - State:CO
Mailing Address - Zip Code:80504-5211
Mailing Address - Country:US
Mailing Address - Phone:720-600-0370
Mailing Address - Fax:
Practice Address - Street 1:11169 E I25 FRONTAGE RD STE C
Practice Address - Street 2:
Practice Address - City:FIRESTONE
Practice Address - State:CO
Practice Address - Zip Code:80504-5211
Practice Address - Country:US
Practice Address - Phone:720-600-0370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-23
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18105225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist