Provider Demographics
NPI:1962244624
Name:STOUT, GRAYSON TYLER (DPT)
Entity type:Individual
Prefix:
First Name:GRAYSON
Middle Name:TYLER
Last Name:STOUT
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24451 INWOOD AVE N
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-8375
Mailing Address - Country:US
Mailing Address - Phone:651-325-7463
Mailing Address - Fax:
Practice Address - Street 1:2270 FORD PKWY STE 200
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-3412
Practice Address - Country:US
Practice Address - Phone:612-672-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-12
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13531225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist