Healthcare Provider Details

I. General information

NPI: 1457255242
Provider Name (Legal Business Name): ATK MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3465 N PINES WAY STE 105
WILSON WY
83014-9128
US

IV. Provider business mailing address

PO BOX 1168
WILSON WY
83014-1168
US

V. Phone/Fax

Practice location:
  • Phone: 307-355-1553
  • Fax:
Mailing address:
  • Phone: 307-355-1553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: AILIS TWEED-KENT
Title or Position: PHYSICIAN
Credential: MD
Phone: 307-355-1553