Healthcare Provider Details

I. General information

NPI: 1841342821
Provider Name (Legal Business Name): WIND RIVER ANESTHESIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 03/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 WILKINS CIRCLE
CASPER WY
82601
US

IV. Provider business mailing address

PO BOX 1363
IDAHO FALLS ID
83403-1363
US

V. Phone/Fax

Practice location:
  • Phone: 307-265-1792
  • Fax:
Mailing address:
  • Phone: 208-525-2090
  • Fax: 208-525-2662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number6058A
License Number StateWY

VIII. Authorized Official

Name: JEFFREY FOWLER
Title or Position: OWNER
Credential: MD
Phone: 208-525-2090