Healthcare Provider Details

I. General information

NPI: 1073209441
Provider Name (Legal Business Name): HIGH COUNTRY PRIMARY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

389 ADAMS ST
AFTON WY
83110-5056
US

IV. Provider business mailing address

PO BOX 376
AFTON WY
83110-0376
US

V. Phone/Fax

Practice location:
  • Phone: 307-885-9883
  • Fax:
Mailing address:
  • Phone: 307-885-9883
  • Fax: 307-885-5206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: SHANNON NIZER
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 307-885-9883