Provider Demographics
NPI:1013451566
Name:LANDERMAN, JON
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:LANDERMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 MORGAN AVE
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-5229
Mailing Address - Country:US
Mailing Address - Phone:307-362-9035
Mailing Address - Fax:
Practice Address - Street 1:431 MORGAN AVE
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-5229
Practice Address - Country:US
Practice Address - Phone:307-362-9035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-16
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator