Healthcare Provider Details

I. General information

NPI: 1063467538
Provider Name (Legal Business Name): BRENT BLUE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 12/23/2025
Certification Date: 12/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 MUSTANG DRIVE
DRIGGS ID
83422-0000
US

IV. Provider business mailing address

PO BOX 25
WILSON WY
83014-0025
US

V. Phone/Fax

Practice location:
  • Phone: 307-733-7835
  • Fax: 307-733-6912
Mailing address:
  • Phone: 307-733-7835
  • Fax: 307-733-6912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA31472
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number3416A
License Number StateWY
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3416A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: