Healthcare Provider Details

I. General information

NPI: 1992744817
Provider Name (Legal Business Name): WIND RIVER OBSTETRICS AND GYNECOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 05/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 COLLEGE VIEW DR
RIVERTON WY
82501-2266
US

IV. Provider business mailing address

1005 COLLEGE VIEW DR
RIVERTON WY
82501-2289
US

V. Phone/Fax

Practice location:
  • Phone: 307-857-5217
  • Fax: 307-857-5215
Mailing address:
  • Phone: 307-856-4232
  • Fax: 307-856-4243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number6798A
License Number StateWY

VIII. Authorized Official

Name: MARYANNE A HANNANEY
Title or Position: CEO
Credential: MD
Phone: 307-857-3488