=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689670267
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHILLIP O TIGERT PAC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2005
-----------------------------------------------------
Last Update Date | 12/19/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 S 5TH ST
-----------------------------------------------------
City | DOUGLAS
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82633-2434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-358-7300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 S 5TH ST
-----------------------------------------------------
City | DOUGLAS
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82633-2434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-358-7300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 0364
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------