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General NPI Number Information
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NPI Number | 1760603138
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Entity Type | Organization
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Legal Business Name | EAR, NOSE & THROAT CENTER OF WYOMING, LLC
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Dates
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Enumeration Date | 05/01/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 196 ARROWHEAD DR STE 5
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City | EVANSTON
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State | WY
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Zip | 82930-8752
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Country | US
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Telephone | 801-328-2522
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Fax |
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Provider Business Mailing Address
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Address Line | 22 S 900 E
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City | SLC
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State | UT
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Zip | 84102-1307
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | BILLING
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Name | EVON PEFAUR
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Credential |
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Telephone | 801-328-2522
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | 2005000496155
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License Number State | WY
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