Healthcare Provider Details

I. General information

NPI: 1518479104
Provider Name (Legal Business Name): JUSTIN GERALD TATTERSALL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2017
Last Update Date: 11/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 E BROADWAY AVE
JACKSON WY
83001-8642
US

IV. Provider business mailing address

PO BOX 9871
JACKSON WY
83002-9871
US

V. Phone/Fax

Practice location:
  • Phone: 307-733-3636
  • Fax:
Mailing address:
  • Phone: 307-413-0437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number30955
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: