Provider Demographics
NPI:1689052219
Name:WARD, KEVIN WESLEY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:WESLEY
Last Name:WARD
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 1:1800 FLANDRO DR
Mailing Address - Street 2:SUITE 190
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-4912
Mailing Address - Country:US
Mailing Address - Phone:208-233-2248
Mailing Address - Fax:
Practice Address - Street 1:1800 FLANDRO DR
Practice Address - Street 2:SUITE 190
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83202-4912
Practice Address - Country:US
Practice Address - Phone:208-233-2248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-15
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2386225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist