Healthcare Provider Details

I. General information

NPI: 1194210328
Provider Name (Legal Business Name): VILLA ANESTHESIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2018
Last Update Date: 06/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 E 2ND ST
CASPER WY
82601-2926
US

IV. Provider business mailing address

742 S DAVID ST
CASPER WY
82601-3137
US

V. Phone/Fax

Practice location:
  • Phone: 307-577-7201
  • Fax:
Mailing address:
  • Phone: 307-234-9657
  • Fax: 307-234-0306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberTL4408
License Number StateWY

VIII. Authorized Official

Name: MRS. MARGUERITE HARDY
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 307-234-9657