Provider Demographics
NPI:1649560764
Name:EGLESTON, PAUL ALLEN (PA-C)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:ALLEN
Last Name:EGLESTON
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 1:428 S DURBIN ST
Mailing Address - Street 2:STE 104
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2818
Mailing Address - Country:US
Mailing Address - Phone:307-337-4284
Mailing Address - Fax:307-462-0922
Practice Address - Street 1:2761 COMMERCIAL WAY
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-4753
Practice Address - Country:US
Practice Address - Phone:307-382-3064
Practice Address - Fax:307-382-3303
Is Sole Proprietor?:No
Enumeration Date:2011-04-11
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPA630363A00000X
UT6306798-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant