Provider Demographics
NPI:1215942099
Name:GARDNER, MISTY D (MS, DPT)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:D
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MS, DPT
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 306
Mailing Address - Street 2:
Mailing Address - City:BIG HORN
Mailing Address - State:WY
Mailing Address - Zip Code:82833-0306
Mailing Address - Country:US
Mailing Address - Phone:307-752-9335
Mailing Address - Fax:
Practice Address - Street 1:1333 W 5TH ST
Practice Address - Street 2:SUITE 203
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-2752
Practice Address - Country:US
Practice Address - Phone:307-752-9335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-30
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT1154225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY123365300Medicaid
WY123365300Medicaid