Healthcare Provider Details

I. General information

NPI: 1982775508
Provider Name (Legal Business Name): WOMENS CLINIC OF NORTHEASTERN WYOMING PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 10/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 W BURKITT ST
SHERIDAN WY
82801-4206
US

IV. Provider business mailing address

212 W BURKITT ST
SHERIDAN WY
82801-4206
US

V. Phone/Fax

Practice location:
  • Phone: 307-672-0401
  • Fax: 307-672-0317
Mailing address:
  • Phone: 307-672-0401
  • Fax: 307-672-0317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2719A
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number13730119
License Number StateWY

VIII. Authorized Official

Name: TIMOTHY JAMES SCOTT
Title or Position: PRESIDENT OF PC
Credential: MD
Phone: 307-672-0401