Healthcare Provider Details

I. General information

NPI: 1619153038
Provider Name (Legal Business Name): WILSON GYNECOLOGY CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2008
Last Update Date: 03/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5235 HHR ROAD
WILSON WY
83014
US

IV. Provider business mailing address

PO BOX 243
WILSON WY
83014-0243
US

V. Phone/Fax

Practice location:
  • Phone: 307-733-5676
  • Fax:
Mailing address:
  • Phone: 307-733-5676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number5262A
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number5262A
License Number StateWY

VIII. Authorized Official

Name: ROGER M BRECHEEN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 307-733-5676