| NPI | 1295494037 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | ERIN PETERSEN Payer Enrollment Specialist 307-432-3664 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine |
| Additional Taxonomies | 208600000X Surgery |
| 213E00000X Podiatrist | |
| 208D00000X General Practice | |
| Enumeration Date | 2021-12-09 |
| Last Update Date | 2025-09-04 |