Healthcare Provider Details

I. General information

NPI: 1477542231
Provider Name (Legal Business Name): SURGICAL ASSOCIATES OF NORTHERN WYOMING, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 12/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 9TH ST
CODY WY
82414-3433
US

IV. Provider business mailing address

449 MOUNTAIN VIEW ST
POWELL WY
82435-2232
US

V. Phone/Fax

Practice location:
  • Phone: 307-587-1257
  • Fax: 307-587-7394
Mailing address:
  • Phone: 307-754-4559
  • Fax: 307-754-7733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES L JOHNSON II
Title or Position: PRESIDENT
Credential: M.D.
Phone: 307-587-1257