Healthcare Provider Details

I. General information

NPI: 1518118017
Provider Name (Legal Business Name): WIND RIVER PODIATRIC MEDICINE AND SURGERY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2008
Last Update Date: 09/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 COLLEGE VIEW DR SUITE 4
RIVERTON WY
82501-2266
US

IV. Provider business mailing address

1005 COLLEGE VIEW DR SUITE 4
RIVERTON WY
82501-2266
US

V. Phone/Fax

Practice location:
  • Phone: 307-857-3488
  • Fax: 307-857-5215
Mailing address:
  • Phone: 307-857-3488
  • Fax: 307-857-5215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number130
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: AARON D DONALDSON
Title or Position: SOLE OWNER
Credential: DPM
Phone: 307-857-3488