=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578511036
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WYOMING OTOLARYNGOLOGY, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2006
-----------------------------------------------------
Last Update Date | 07/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6500 E 2ND ST SUITE 101
-----------------------------------------------------
City | CASPER
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82609-4338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-577-4242
-----------------------------------------------------
Fax | 307-577-0012
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6500 E 2ND ST SUITE 101
-----------------------------------------------------
City | CASPER
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82609-4338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-577-4242
-----------------------------------------------------
Fax | 307-577-0012
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | SHELIA S ELLIOTT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 307-577-4242
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332S00000X
-----------------------------------------------------
Taxonomy Name | Hearing Aid Equipment
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------
=====================================================
Legacy Identifiers
=====================================================
Identifier #1
-----------------------------------------------------
Identifier Code | 106280800
-----------------------------------------------------
Identifier Type | MEDICAID
-----------------------------------------------------
Identifier State | WY
-----------------------------------------------------
Identifier Issuer |
-----------------------------------------------------
=====================================================
Proprietary Identifiers Ever Reported
=====================================================
Identifier #1
-----------------------------------------------------
Identifier Code | 106280800
-----------------------------------------------------
Identifier Type | MEDICAID
-----------------------------------------------------
Identifier State | WY
-----------------------------------------------------
Identifier Issuer |
-----------------------------------------------------