Provider Demographics
NPI:1902317068
Name:RADAKOVICH, NORA
Entity Type:Individual
Prefix:
First Name:NORA
Middle Name:
Last Name:RADAKOVICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2722 CHERRYWOOD LN
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-4346
Mailing Address - Country:US
Mailing Address - Phone:307-350-6592
Mailing Address - Fax:
Practice Address - Street 1:1325 SAGE ST
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-7478
Practice Address - Country:US
Practice Address - Phone:307-362-3780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY0360225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant