Provider Demographics
NPI:1760083851
Name:DESIMONE, THOMAS JAMES (MS, ATC, LAT, PES)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JAMES
Last Name:DESIMONE
Suffix:
Gender:M
Credentials:MS, ATC, LAT, PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 HACIENDA CT
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82007-1329
Mailing Address - Country:US
Mailing Address - Phone:203-448-6531
Mailing Address - Fax:
Practice Address - Street 1:1000 E UNIVERSITY AVE DEPT 3414
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82071-2000
Practice Address - Country:US
Practice Address - Phone:307-766-2060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1512255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer