Healthcare Provider Details

I. General information

NPI: 1639203664
Provider Name (Legal Business Name): BRANDON VASHON MACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 COLLEGE DR
ROCK SPRINGS WY
82901-5868
US

IV. Provider business mailing address

1200 COLLEGE DR P.O. BOX 1359
ROCK SPRINGS WY
82901-5868
US

V. Phone/Fax

Practice location:
  • Phone: 307-352-8326
  • Fax: 307-352-8502
Mailing address:
  • Phone: 307-352-8326
  • Fax: 307-352-8502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberTL799
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: