Provider Demographics
NPI:1417048810
Name:WYOMING RECONSTRUCTIVE & PLASTIC SURGERY LLC
Entity Type:Organization
Organization Name:WYOMING RECONSTRUCTIVE & PLASTIC SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXTERNAL FINANCIAL CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:STUTTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-577-2767
Mailing Address - Street 1:PO BOX 51076
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82605
Mailing Address - Country:US
Mailing Address - Phone:307-472-4300
Mailing Address - Fax:307-472-4311
Practice Address - Street 1:918 E 2ND ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2625
Practice Address - Country:US
Practice Address - Phone:307-472-4300
Practice Address - Fax:307-472-4311
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WYOMING MEDICAL CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-28
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY06059001OtherBLUE CROSS BLUE SHIELD
WYDF9302OtherRAILROAD MEDICARE
WYDF9302OtherRAILROAD MEDICARE