Provider Demographics
NPI:1093713067
Name:TICHENOR, ROWAN E (MD)
Entity Type:Individual
Prefix:
First Name:ROWAN
Middle Name:E
Last Name:TICHENOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1119 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2905
Mailing Address - Country:US
Mailing Address - Phone:307-266-2772
Mailing Address - Fax:307-266-2076
Practice Address - Street 1:1119 E 3RD ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2905
Practice Address - Country:US
Practice Address - Phone:307-266-2772
Practice Address - Fax:307-266-2076
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY2634A207N00000X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
070011534OtherRR MEDICARE
WY106641200Medicaid
W301989Medicare PIN
WY106641200Medicaid