Provider Demographics
NPI:1669518668
Name:WESTERN WYOMING DERMATOLOGY & SURGERY PC
Entity type:Organization
Organization Name:WESTERN WYOMING DERMATOLOGY & SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:BROOK
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:307-734-5864
Mailing Address - Street 1:P.O. BOX 7406
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002
Mailing Address - Country:US
Mailing Address - Phone:307-734-5864
Mailing Address - Fax:307-734-5866
Practice Address - Street 1:62 REDMOND STREET
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83002-7406
Practice Address - Country:US
Practice Address - Phone:307-734-5864
Practice Address - Fax:307-734-5866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2009-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7168A207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY20239Medicare ID - Type UnspecifiedGROUP NUMBER