Provider Demographics
NPI:1538192810
Name:ELSASSER, ROCKY WADE (DPT)
Entity type:Individual
Prefix:
First Name:ROCKY
Middle Name:WADE
Last Name:ELSASSER
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 1:2176 E FRANKLIN RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9024
Mailing Address - Country:US
Mailing Address - Phone:208-288-1155
Mailing Address - Fax:208-288-0424
Practice Address - Street 1:943 N LINDER RD
Practice Address - Street 2:SUITE 104
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:63634-3395
Practice Address - Country:US
Practice Address - Phone:208-922-1719
Practice Address - Fax:208-922-1721
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT49332238-2401225100000X
IDPT-2180225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807785000Medicaid
ID1651504Medicare PIN
UTQ68898Medicare UPIN
UT005581106Medicare ID - Type Unspecified