Healthcare Provider Details

I. General information

NPI: 1467521955
Provider Name (Legal Business Name): WYATT JEROME KRAMER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 ALDEN DR
CHEYENNE WY
82005-3906
US

IV. Provider business mailing address

5500 BISHOP BLVD
CHEYENNE WY
82009-3320
US

V. Phone/Fax

Practice location:
  • Phone: 307-773-2359
  • Fax:
Mailing address:
  • Phone: 307-772-5387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number393
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: