Healthcare Provider Details

I. General information

NPI: 1124188545
Provider Name (Legal Business Name): ANTELOPE MEDICAL CONSULTANTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 S MEDICAL ARTS CT
GILLETTE WY
82716-3364
US

IV. Provider business mailing address

430 S MEDICAL ARTS CT
GILLETTE WY
82716-3364
US

V. Phone/Fax

Practice location:
  • Phone: 307-682-7661
  • Fax: 307-682-5074
Mailing address:
  • Phone: 307-682-7661
  • Fax: 307-682-5074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5806A
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number5853A
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number18882.269
License Number StateWY

VIII. Authorized Official

Name: DR. LISA ANNE MALODY
Title or Position: OWNER
Credential: M.D.
Phone: 307-682-7661