Provider Demographics
NPI:1578848487
Name:MORTENSON, DUANE BRUCE (PA-C)
Entity Type:Individual
Prefix:
First Name:DUANE
Middle Name:BRUCE
Last Name:MORTENSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-0428
Mailing Address - Country:US
Mailing Address - Phone:307-733-8002
Mailing Address - Fax:077-330-0323
Practice Address - Street 1:555 E BROADWAY AVE STE 207
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8640
Practice Address - Country:US
Practice Address - Phone:307-733-8002
Practice Address - Fax:307-733-0032
Is Sole Proprietor?:No
Enumeration Date:2011-10-12
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPA818363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY137513000Medicaid