Healthcare Provider Details

I. General information

NPI: 1306769096
Provider Name (Legal Business Name): WYOMING CLINIC OF MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

528 COFFEEN AVE
SHERIDAN WY
82801-5312
US

IV. Provider business mailing address

528 COFFEEN AVE
SHERIDAN WY
82801-5312
US

V. Phone/Fax

Practice location:
  • Phone: 307-683-7138
  • Fax: 307-655-8770
Mailing address:
  • Phone: 307-683-7138
  • Fax: 307-655-8770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: GORDON HENDRICKSON
Title or Position: OWNER
Credential: PA-C
Phone: 307-683-7138