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4621 Sw Wyoming Blvd Casper WY 82601-6702 | |
| (307) 439-0100 | |
| (307) 439-1062 |
| Full Name | |
|---|---|
| Speciality | Clinic/center |
| Location | 4621 Sw Wyoming Blvd, Casper, Wyoming |
| Authorized Official Name and Position | Jason B Whitman (PRESIDENT) |
| Authorized Official Contact | 3074390100 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
4621 Sw Wyoming Blvd Casper WY 82601-6702 Ph: (307) 439-0100 | 4621 Sw Wyoming Blvd Casper WY 82601-6702 Ph: (307) 439-0100 |
| NPI Number | 1760655054 |
|---|---|
| Provider Enumeration Date | 04/08/2008 |
| Last Update Date | 05/24/2022 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1760655054 | NPI | - | NPPES |
| 155826900 | Medicaid | WY |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261Q00000X | Clinic/center | 282T (Wyoming) | Primary |
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