=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073064705
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACK HILDNER PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2016
-----------------------------------------------------
Last Update Date | 10/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 WEST MAIN STREET
-----------------------------------------------------
City | RIVERTON
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-856-6591
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4390 WEST MOUNTIAN VIEW DRIVE
-----------------------------------------------------
City | RIVERTON
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-851-1256
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282NC0060X
-----------------------------------------------------
Taxonomy Name | Critical Access Hospital
-----------------------------------------------------
License Number | 15067
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------