Healthcare Provider Details

I. General information

NPI: 1699316430
Provider Name (Legal Business Name): JEFFREY ANTON SHIDEMAN DNP, NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2019
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 S GOULD ST
SHERIDAN WY
82801-6304
US

IV. Provider business mailing address

1333 W 5TH ST STE 110
SHERIDAN WY
82801-2752
US

V. Phone/Fax

Practice location:
  • Phone: 307-675-2690
  • Fax:
Mailing address:
  • Phone: 307-675-2650
  • Fax: 307-675-2651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number44709
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: