Provider Demographics
NPI:1578511036
Name:WYOMING OTOLARYNGOLOGY, P.C.
Entity Type:Organization
Organization Name:WYOMING OTOLARYNGOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHELIA
Authorized Official - Middle Name:S
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-577-4242
Mailing Address - Street 1:6500 E 2ND ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-4338
Mailing Address - Country:US
Mailing Address - Phone:307-577-4242
Mailing Address - Fax:307-577-0012
Practice Address - Street 1:6500 E 2ND ST
Practice Address - Street 2:SUITE 101
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-4338
Practice Address - Country:US
Practice Address - Phone:307-577-4242
Practice Address - Fax:307-577-0012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY207Y00000X
332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No332S00000XSuppliersHearing Aid EquipmentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY106280800Medicaid
WYW4730475Medicare ID - Type UnspecifiedGROUP #