Provider Demographics
NPI:1619228186
Name:WOOD, ROBERT DANIEL
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:DANIEL
Last Name:WOOD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DAN
Other - Middle Name:
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP-C
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:307-739-7696
Mailing Address - Fax:307-739-4877
Practice Address - Street 1:5235 HHR RANCH RD
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:WY
Practice Address - Zip Code:83014-9210
Practice Address - Country:US
Practice Address - Phone:307-739-7696
Practice Address - Fax:307-739-4877
Is Sole Proprietor?:No
Enumeration Date:2012-09-25
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1417363LF0000X
MTNUR-RN-LIC-49051363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY141422400Medicaid