Healthcare Provider Details

I. General information

NPI: 1093713067
Provider Name (Legal Business Name): ROWAN E TICHENOR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 07/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1119 E 3RD ST
CASPER WY
82601-2905
US

IV. Provider business mailing address

1119 E 3RD ST
CASPER WY
82601-2905
US

V. Phone/Fax

Practice location:
  • Phone: 307-266-2772
  • Fax: 307-266-2076
Mailing address:
  • Phone: 307-266-2772
  • Fax: 307-266-2076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2634A
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number2634A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: