Healthcare Provider Details

I. General information

NPI: 1578848487
Provider Name (Legal Business Name): DUANE BRUCE MORTENSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2011
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 E BROADWAY AVE STE 207
JACKSON WY
83001-8640
US

IV. Provider business mailing address

PO BOX 428
JACKSON WY
83001-0428
US

V. Phone/Fax

Practice location:
  • Phone: 307-733-8002
  • Fax: 307-733-0032
Mailing address:
  • Phone: 307-733-8002
  • Fax: 77-330-0323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA818
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: