Provider Demographics
NPI:1164427274
Name:EDSTROM, JEFFERY W
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:W
Last Name:EDSTROM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JEFF
Other - Middle Name:W
Other - Last Name:EDSTROM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:553 N PINNACLE DR
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:WY
Mailing Address - Zip Code:82834-1416
Mailing Address - Country:US
Mailing Address - Phone:307-684-7817
Mailing Address - Fax:
Practice Address - Street 1:497 W LOTT ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:WY
Practice Address - Zip Code:82834-1658
Practice Address - Country:US
Practice Address - Phone:307-684-5521
Practice Address - Fax:307-684-5385
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI129337367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43403300Medicaid
P15494Medicare UPIN
WI004134217Medicare ID - Type Unspecified
WI211050115Medicare Oscar/Certification