Provider Demographics
NPI:1396967501
Name:GORST, CRAIG M (PT)
Entity type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:M
Last Name:GORST
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 1:2035 HAMILTON ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-1706
Mailing Address - Country:US
Mailing Address - Phone:920-379-7695
Mailing Address - Fax:
Practice Address - Street 1:717 E ALFRED ST
Practice Address - Street 2:
Practice Address - City:WEYAUWEGA
Practice Address - State:WI
Practice Address - Zip Code:54983-9024
Practice Address - Country:US
Practice Address - Phone:920-867-3121
Practice Address - Fax:920-867-3997
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5191-024225100000X, 2251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40260200Medicaid