Healthcare Provider Details

I. General information

NPI: 1144328949
Provider Name (Legal Business Name): JARED BRECK BARTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 10/23/2013
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 Code208600000X
TaxonomySurgery Physician
License Number12367
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberTL1200
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: