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NPI Code Detail

MEDICARE: JEFFERY W EDSTROM

MEDICARE: JEFFERY W EDSTROM
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1367500000XCertified Registered Nurse Anesthetist129337WI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1164427274
Entity Type Code : Individual
Provider Name (Legal Business Name) : JEFFERY W EDSTROM
Provider Business Mailing Address
First Line : 553 N PINNACLE DR
Second Line :
City : BUFFALO
State : WY
Zip : 82834-1416
Country : US
Telephone Number : 307-684-7817
Fax Number :
Provider Business Practice Location Address
First Line : 497 W LOTT ST
Second Line :
City : BUFFALO
State : WY
Zip : 82834-1658
Country : US
Telephone Number : 307-684-5521
Fax Number : 307-684-5385
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/15/2005
Last Update Date : 06/03/2014

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Directions to “ JEFFERY W EDSTROM ” Practice Location

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