=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417710351
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON PERRY NRP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2024
-----------------------------------------------------
Last Update Date | 02/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 502 STOCKTRAIL AVE
-----------------------------------------------------
City | GILLETTE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82716-3554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-688-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 341
-----------------------------------------------------
City | HULETT
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82720-0341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-290-0111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207PE0004X
-----------------------------------------------------
Taxonomy Name | Emergency Medical Services (Emergency Medicine) Physician
-----------------------------------------------------
License Number | 11612
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------