Healthcare Provider Details

I. General information

NPI: 1043085020
Provider Name (Legal Business Name): WYCO DERM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2023
Last Update Date: 11/20/2023
Certification Date: 11/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8305 WELLINGTON BLVD UNIT 102
WELLINGTON CO
80549-2399
US

IV. Provider business mailing address

2112 SEYMOUR AVE
CHEYENNE WY
82001-3830
US

V. Phone/Fax

Practice location:
  • Phone: 307-635-8299
  • Fax: 307-635-6984
Mailing address:
  • Phone: 307-635-8299
  • Fax: 307-635-6984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. GREGORY W SEITZ
Title or Position: OWNER
Credential: MD
Phone: 307-635-8299