Healthcare Provider Details

I. General information

NPI: 1073064705
Provider Name (Legal Business Name): JACK HILDNER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2016
Last Update Date: 10/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 WEST MAIN STREET
RIVERTON WY
82501
US

IV. Provider business mailing address

4390 WEST MOUNTIAN VIEW DRIVE
RIVERTON WY
82501
US

V. Phone/Fax

Practice location:
  • Phone: 307-856-6591
  • Fax:
Mailing address:
  • Phone: 307-851-1256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number15067
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: