MEDICARE: MR. DYLAN POWELL PA-C

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
1	363AM0700X	Medical Physician Assistant	437	WY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1457548083	OTHER	WY	NPI

General Provider Information

NPI Number	:	1457548083
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DYLAN POWELL PA-C

Provider Business Mailing Address
First Line	:	2751 COMMERCIAL WAY
Second Line	:
City	:	ROCK SPRINGS
State	:	WY
Zip	:	82901-4753
Country	:	US
Telephone Number	:	307-382-7414
Fax Number	:	307-382-7396

Provider Business Practice Location Address
First Line	:	2751 COMMERCIAL WAY
Second Line	:
City	:	ROCK SPRINGS
State	:	WY
Zip	:	82901-4753
Country	:	US
Telephone Number	:	307-382-7414
Fax Number	:	307-382-7396

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2007
Last Update Date	:	01/08/2014

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