Provider Demographics
NPI:1336334531
Name:VANHATTEN, BRIAN (PT, OCS)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:VANHATTEN
Suffix:
Gender:M
Credentials:PT, OCS
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 9163
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-9163
Mailing Address - Country:US
Mailing Address - Phone:307-733-7173
Mailing Address - Fax:
Practice Address - Street 1:970 W BROADWAY
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-9475
Practice Address - Country:US
Practice Address - Phone:307-733-7173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY325225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYQ03852Medicare UPIN