| NPI | 1902786676 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | ERIN PETERSEN Payer Enrollment Specialist 307-432-3664 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 208D00000X General Practice |
| Additional Taxonomies | 207R00000X Internal Medicine |
| 208800000X Urology | |
| 363L00000X Nurse Practitioner | |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2025-09-04 |
| Last Update Date | 2025-09-04 |