Provider Demographics
NPI:1386672996
Name:CENTRAL WYOMING NEUROLOGY, LLC
Entity Type:Organization
Organization Name:CENTRAL WYOMING NEUROLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELO
Authorized Official - Middle Name:M
Authorized Official - Last Name:SANTIAGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-234-9037
Mailing Address - Street 1:5820 E.2ND ST.
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-4308
Mailing Address - Country:US
Mailing Address - Phone:307-234-9037
Mailing Address - Fax:307-234-9042
Practice Address - Street 1:5820 E.2ND ST.
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-4308
Practice Address - Country:US
Practice Address - Phone:307-234-9037
Practice Address - Fax:307-234-9042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5622A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY120297900Medicaid
WY05674001OtherBCBS OF WY
WY120297900Medicaid