Provider Demographics
NPI:1821805375
Name:ANDERSON, SCOTT GORDON
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:GORDON
Last Name:ANDERSON
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:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:ST STEPHENS
Mailing Address - State:WY
Mailing Address - Zip Code:82524-0190
Mailing Address - Country:US
Mailing Address - Phone:307-856-8090
Mailing Address - Fax:307-463-4254
Practice Address - Street 1:450 S FEDERAL BLVD
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-4711
Practice Address - Country:US
Practice Address - Phone:307-856-8090
Practice Address - Fax:307-463-4254
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-17
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY177175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty