Provider Demographics
NPI:1760603138
Name:EAR, NOSE & THROAT CENTER OF WYOMING, LLC
Entity Type:Organization
Organization Name:EAR, NOSE & THROAT CENTER OF WYOMING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:EVON
Authorized Official - Middle Name:
Authorized Official - Last Name:PEFAUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-328-2522
Mailing Address - Street 1:22 S 900 E
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:196 ARROWHEAD DR STE 5
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-8752
Practice Address - Country:US
Practice Address - Phone:801-328-2522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY2005000496155207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty