Healthcare Provider Details

I. General information

NPI: 1851535793
Provider Name (Legal Business Name): PREMISE HEALTH OF WYOMING MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2009
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 S MEDICAL ARTS CT
GILLETTE WY
82716-3364
US

IV. Provider business mailing address

5500 MARYLAND WAY STE 120
BRENTWOOD TN
37027-4993
US

V. Phone/Fax

Practice location:
  • Phone: 307-685-6500
  • Fax: 307-685-3081
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateWY

VIII. Authorized Official

Name: DR. JONATHAN LEIZMAN
Title or Position: PRESIDENT
Credential: MD
Phone: 216-479-9063