Healthcare Provider Details

I. General information

NPI: 1477516540
Provider Name (Legal Business Name): DAVID K. CUSTIS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S BURMA AVE
GILLETTE WY
82716-3426
US

IV. Provider business mailing address

PO BOX 3011
GILLETTE WY
82717-3011
US

V. Phone/Fax

Practice location:
  • Phone: 307-688-3636
  • Fax: 307-688-7920
Mailing address:
  • Phone: 307-688-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA832
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: