Provider Demographics
NPI:1265425920
Name:WARD, GARY L (ATC, PT)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:WARD
Suffix:
Gender:M
Credentials:ATC, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5048 N FARM ROAD 185
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-8441
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 S NATIONAL AVE
Practice Address - Street 2:MISSOURI STATE UNIVERSITY
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-0027
Practice Address - Country:US
Practice Address - Phone:417-836-8553
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0000122255A2300X
MOR0321225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist