Provider Demographics
NPI:1093854614
Name:SWAN, DAVIS M (MD)
Entity Type:Individual
Prefix:
First Name:DAVIS
Middle Name:M
Last Name:SWAN
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:PO BOX 767
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-0767
Mailing Address - Country:US
Mailing Address - Phone:307-674-5123
Mailing Address - Fax:307-674-5230
Practice Address - Street 1:1401 W 5TH ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-2705
Practice Address - Country:US
Practice Address - Phone:307-672-7874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3149A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0020241OtherMONTANA MEDICAID PIN
WY302093OtherBCBS OF WYO PIN
WY103886900Medicaid
WY302093Medicare PIN
WY302093OtherBCBS OF WYO PIN
WY103886900Medicaid