Healthcare Provider Details

I. General information

NPI: 1396305207
Provider Name (Legal Business Name): SAMUEL DAVID CROSS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2019
Last Update Date: 10/05/2022
Certification Date: 09/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 BLUE SKY HWY
ETHETE WY
82520
US

IV. Provider business mailing address

363 SWEETWATER ST FL 2
LANDER WY
82520-3347
US

V. Phone/Fax

Practice location:
  • Phone: 307-856-9281
  • Fax:
Mailing address:
  • Phone: 480-221-5408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number14953A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: