Healthcare Provider Details

I. General information

NPI: 1386639797
Provider Name (Legal Business Name): CHEYENNE ORTHOPAEDICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 03/20/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5320 EDUCATION DR
CHEYENNE WY
82009-4058
US

IV. Provider business mailing address

5320 EDUCATION DR
CHEYENNE WY
82009-4058
US

V. Phone/Fax

Practice location:
  • Phone: 307-632-9261
  • Fax: 307-634-9170
Mailing address:
  • Phone: 307-632-9261
  • Fax: 307-634-9170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JEAN D BASTA
Title or Position: PARTNER
Credential: MD
Phone: 307-263-1773