Provider Demographics
NPI:1790216398
Name:KILLIAN, JOEL
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:KILLIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 S LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-4709
Mailing Address - Country:US
Mailing Address - Phone:307-684-9271
Mailing Address - Fax:
Practice Address - Street 1:1 N DESMET AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:WY
Practice Address - Zip Code:82834-1812
Practice Address - Country:US
Practice Address - Phone:307-684-9271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1131225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist