Provider Demographics
NPI:1194908194
Name:PEDRICK, REED L (PT)
Entity type:Individual
Prefix:
First Name:REED
Middle Name:L
Last Name:PEDRICK
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 1:3125 E GRAND AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-5137
Mailing Address - Country:US
Mailing Address - Phone:307-742-3110
Mailing Address - Fax:
Practice Address - Street 1:3125 E GRAND AVE
Practice Address - Street 2:SUITE A
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-5137
Practice Address - Country:US
Practice Address - Phone:307-742-3110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-12
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT-0036225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW305352Medicare PIN