Healthcare Provider Details

I. General information

NPI: 1740410240
Provider Name (Legal Business Name): PLATTE RIVER ANESTHESIOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2009
Last Update Date: 01/16/2014
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 Number8406A
License Number StateWY

VIII. Authorized Official

Name: RYAN M BURTON
Title or Position: PRESIDENT
Credential: MD
Phone: 206-719-7150