Provider Demographics
NPI:1104924877
Name:BURTON, GREG R (PT)
Entity type:Individual
Prefix:DR
First Name:GREG
Middle Name:R
Last Name:BURTON
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 395
Mailing Address - Street 2:
Mailing Address - City:LOVELL
Mailing Address - State:WY
Mailing Address - Zip Code:82431-0395
Mailing Address - Country:US
Mailing Address - Phone:307-887-6202
Mailing Address - Fax:
Practice Address - Street 1:186 E MAIN ST STE 331
Practice Address - Street 2:
Practice Address - City:LOVELL
Practice Address - State:WY
Practice Address - Zip Code:82431-2004
Practice Address - Country:US
Practice Address - Phone:307-887-6202
Practice Address - Fax:702-474-7458
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT768225100000X
NV3193225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY117014700Medicaid
WY308087OtherBLUE CROSS BLUE SHIELD
WY308087OtherBLUE CROSS BLUE SHIELD