Provider Demographics
NPI:1851317044
Name:SPEAS, GARY OWEN (PT)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:OWEN
Last Name:SPEAS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:957 BLACK DRIVE #A
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-1403
Mailing Address - Country:US
Mailing Address - Phone:928-778-9898
Mailing Address - Fax:927-771-9159
Practice Address - Street 1:957 BLACK DRIVE #A
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-1403
Practice Address - Country:US
Practice Address - Phone:928-778-9898
Practice Address - Fax:928-771-9159
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ960225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00340387OtherRAILROAD MEDICARE PIN
AZZ111186Medicare PIN
AZP00340387OtherRAILROAD MEDICARE PIN