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NPI Code Detail

MEDICARE: FRONTIER SPINE AND ORTHOPEDIC SURGERY, P.C.

MEDICARE: FRONTIER SPINE AND ORTHOPEDIC SURGERY, P.C.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207X00000XOrthopaedic Surgery PhysicianTL4296WY
2207XS0117XOrthopaedic Surgery of the Spine PhysicianTL4296WY

General Provider Information

NPI Number : 1881174431
Entity Type Code : Organization
Provider Name (Legal Business Name) : FRONTIER SPINE AND ORTHOPEDIC SURGERY, P.C.
Provider Business Mailing Address
First Line : 4117 N. 2600 E
Second Line :
City : FILER
State : ID
Zip : 83328
Country : US
Telephone Number : 801-916-0829
Fax Number :
Provider Business Practice Location Address
First Line : 4401 COLLEGE DR
Second Line :
City : ROCK SPRINGS
State : WY
Zip : 82901-3507
Country : US
Telephone Number : 307-352-8930
Fax Number : 307-352-8947
Authorized Official
Title or Position : ORGANIZER
Name : MR. JUSTIN MORONI DAZLEY
Credential : M.D.
Telephone Number : 801-916-0829
Provider Enumeration Date : 08/14/2018
Last Update Date : 08/14/2018

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