MEDICARE: EASTERN WYOMING AMBULANCE SERVICE, INC.

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	3416L0300X	Land Ambulance	127	WY

General Provider Information

NPI Number	:	1619974615
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EASTERN WYOMING AMBULANCE SERVICE, INC.

Provider Business Mailing Address
First Line	:	2450 W MARIPOSA PKWY
Second Line	:
City	:	WHEATLAND
State	:	WY
Zip	:	82201-3112
Country	:	US
Telephone Number	:	307-322-5424
Fax Number	:

Provider Business Practice Location Address
First Line	:	2450 W MARIPOSA PKWY
Second Line	:
City	:	WHEATLAND
State	:	WY
Zip	:	82201-3112
Country	:	US
Telephone Number	:	307-322-5424
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	WADE WELLS
Credential	:	NREMT-P
Telephone Number	:	307-322-5424

Provider Enumeration Date	:	07/05/2005
Last Update Date	:	12/21/2007

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