Healthcare Provider Details

I. General information

NPI: 1295648889
Provider Name (Legal Business Name): ANDREW JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2538 BIG HORN AVE
CODY WY
82414-9299
US

IV. Provider business mailing address

2538 BIG HORN AVE
CODY WY
82414-9299
US

V. Phone/Fax

Practice location:
  • Phone: 307-587-2197
  • Fax: 307-620-7677
Mailing address:
  • Phone: 307-587-2197
  • Fax: 307-620-7677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: