Healthcare Provider Details

I. General information

NPI: 1164427274
Provider Name (Legal Business Name): JEFFERY W EDSTROM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JEFF W EDSTROM CRNA

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 06/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

497 W LOTT ST
BUFFALO WY
82834-1658
US

IV. Provider business mailing address

553 N PINNACLE DR
BUFFALO WY
82834-1416
US

V. Phone/Fax

Practice location:
  • Phone: 307-684-5521
  • Fax: 307-684-5385
Mailing address:
  • Phone: 307-684-7817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number129337
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: