Provider Demographics
NPI:1396815809
Name:NACHTIGAL, TOM A (MD)
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:A
Last Name:NACHTIGAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TOM
Other - Middle Name:A
Other - Last Name:NACHTIGAL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD FACS PC
Mailing Address - Street 1:PO BOX 103
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82073-0103
Mailing Address - Country:US
Mailing Address - Phone:307-760-8468
Mailing Address - Fax:
Practice Address - Street 1:3125 E GRAND AVE
Practice Address - Street 2:SUITE B
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-5137
Practice Address - Country:US
Practice Address - Phone:307-745-8442
Practice Address - Fax:307-742-0036
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY4490A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY116885100Medicaid
E50025Medicare UPIN
W9065Medicare ID - Type Unspecified
WY116885100Medicaid