Healthcare Provider Details

I. General information

NPI: 1952382822
Provider Name (Legal Business Name): ROBERT WADE WASHBURN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 ALDEN DR 90 MDG
FE WARREN AFB WY
82005-3906
US

IV. Provider business mailing address

6900 ALDEN DR 90 MDG
FE WARREN AFB WY
82005-3906
US

V. Phone/Fax

Practice location:
  • Phone: 307-773-3461
  • Fax:
Mailing address:
  • Phone: 307-773-3461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberNCCPA 1045811
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: