Healthcare Provider Details

I. General information

NPI: 1730335423
Provider Name (Legal Business Name): SOUTHWEST WYOMING ENT INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2008
Last Update Date: 10/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 OVERTHRUST RD
EVANSTON WY
82930-9261
US

IV. Provider business mailing address

191 OVERTHRUST RD
EVANSTON WY
82930-9261
US

V. Phone/Fax

Practice location:
  • Phone: 307-789-8721
  • Fax: 307-789-8664
Mailing address:
  • Phone: 307-789-8721
  • Fax: 307-789-8664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: JASON P HAACK
Title or Position: OWNER
Credential: MD
Phone: 307-789-8721