=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003050253
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BIG HORN FOOT CLINIC, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2009
-----------------------------------------------------
Last Update Date | 04/30/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 424 YELLOWSTONE AVE SUITE 140
-----------------------------------------------------
City | CODY
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82414-9318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-527-9191
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 777 AVENUE H
-----------------------------------------------------
City | POWELL
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82435-2260
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-754-9191
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PODIATRIST/OWNER
-----------------------------------------------------
Name | DUNCAN HUGH FRASER
-----------------------------------------------------
Credential | D.P.M.
-----------------------------------------------------
Telephone | 307-527-9191
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 104
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------