Healthcare Provider Details

I. General information

NPI: 1780076364
Provider Name (Legal Business Name): EVANSTON REGIONAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2015
Last Update Date: 02/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

531 PARKWAY DRIVE
MOUNTAIN VIEW WY
82939
US

IV. Provider business mailing address

531 PARKWAY DRIVE
MOUNTAIN VIEW WY
82939
US

V. Phone/Fax

Practice location:
  • Phone: 307-782-7560
  • Fax:
Mailing address:
  • Phone: 307-782-7560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number33582.1375
License Number StateWY

VIII. Authorized Official

Name: ANDREW WILEY
Title or Position: CLINIC SUPERVISOR
Credential:
Phone: 307-789-3636