Provider Demographics
NPI:1518118017
Name:WIND RIVER PODIATRIC MEDICINE AND SURGERY, PC
Entity Type:Organization
Organization Name:WIND RIVER PODIATRIC MEDICINE AND SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AARON
Authorized Official - Middle Name:D
Authorized Official - Last Name:DONALDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:307-857-3488
Mailing Address - Street 1:1005 COLLEGE VIEW DR
Mailing Address - Street 2:SUITE 4
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-2266
Mailing Address - Country:US
Mailing Address - Phone:307-857-3488
Mailing Address - Fax:307-857-5215
Practice Address - Street 1:1005 COLLEGE VIEW DR
Practice Address - Street 2:SUITE 4
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-2266
Practice Address - Country:US
Practice Address - Phone:307-857-3488
Practice Address - Fax:307-857-5215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-02
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY130213E00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1518118017Medicaid
WYD05546OtherRAILROAD MEDICARE
WYD05546OtherRAILROAD MEDICARE
WY6228240001Medicare NSC