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General NPI Number Information
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NPI Number | 1841342821
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Entity Type | Organization
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Legal Business Name | WIND RIVER ANESTHESIA PC
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Dates
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Enumeration Date | 01/18/2007
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Last Update Date | 03/11/2010
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Provider Practice Location Address
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Address Line | 1441 WILKINS CIRCLE
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City | CASPER
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State | WY
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Zip | 82601
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Country | US
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Telephone | 307-265-1792
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1363
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City | IDAHO FALLS
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State | ID
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Zip | 83403-1363
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Country | US
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Telephone | 208-525-2090
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Fax | 208-525-2662
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Authorized Official
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Title or Position | OWNER
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Name | JEFFREY FOWLER
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Credential | MD
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Telephone | 208-525-2090
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 6058A
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License Number State | WY
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