Provider Demographics
NPI:1295959260
Name:WEIRATH, JOHN DANIEL (PT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DANIEL
Last Name:WEIRATH
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:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:FRUITA
Mailing Address - State:CO
Mailing Address - Zip Code:81521-0130
Mailing Address - Country:US
Mailing Address - Phone:970-858-2147
Mailing Address - Fax:970-858-4569
Practice Address - Street 1:551 KOKOPELLI BLVD UNIT E
Practice Address - Street 2:
Practice Address - City:FRUITA
Practice Address - State:CO
Practice Address - Zip Code:81521-6305
Practice Address - Country:US
Practice Address - Phone:970-858-2147
Practice Address - Fax:970-858-4569
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0006015225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1295959260Medicare PIN