Provider Demographics
NPI:1457548083
Name:POWELL, DYLAN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DYLAN
Middle Name:
Last Name:POWELL
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 1:2751 COMMERCIAL WAY
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-4753
Mailing Address - Country:US
Mailing Address - Phone:307-382-7414
Mailing Address - Fax:307-382-7396
Practice Address - Street 1:2751 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:307-382-7414
Practice Address - Fax:307-382-7396
Is Sole Proprietor?:No
Enumeration Date:2007-09-27
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY437363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1457548083OtherNPI