Provider Demographics
NPI:1710271630
Name:BROWN, CLANCY CLYDE (DPT, CSCS)
Entity Type:Individual
Prefix:DR
First Name:CLANCY
Middle Name:CLYDE
Last Name:BROWN
Suffix:
Gender:M
Credentials:DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 PETERSEN PKWY STE 1
Mailing Address - Street 2:
Mailing Address - City:THAYNE
Mailing Address - State:WY
Mailing Address - Zip Code:83127-9754
Mailing Address - Country:US
Mailing Address - Phone:307-883-7878
Mailing Address - Fax:307-883-7877
Practice Address - Street 1:124 PETERSEN PKWY STE 1
Practice Address - Street 2:
Practice Address - City:THAYNE
Practice Address - State:WY
Practice Address - Zip Code:83127-9754
Practice Address - Country:US
Practice Address - Phone:307-883-7878
Practice Address - Fax:307-883-7877
Is Sole Proprietor?:No
Enumeration Date:2011-06-08
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1366225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY121989800Medicaid
WY103956300Medicaid
WY117016300Medicaid
WY1801816897Medicare PIN
WY103956300Medicaid
WY121989800Medicaid
WY117016300Medicaid