Provider Demographics
NPI:1427408319
Name:ADVANCED DERMATOLOGY OF WYOMING, INC
Entity Type:Organization
Organization Name:ADVANCED DERMATOLOGY OF WYOMING, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:CRANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-484-3050
Mailing Address - Street 1:PO BOX 7406
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-7406
Mailing Address - Country:US
Mailing Address - Phone:307-734-5864
Mailing Address - Fax:
Practice Address - Street 1:62 SOUTH REDMOND STREET
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8664
Practice Address - Country:US
Practice Address - Phone:307-734-5864
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-21
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty