MEDICARE: AGESELAOS JOHN MEARES MD

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	207RN0300X	Nephrology Physician	7059A	WY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7059A	OTHER	WY	STATE LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	719AJM04	OTHER	WY	SUBSTANCE CONTROL

General Provider Information

NPI Number	:	1740264357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AGESELAOS JOHN MEARES MD

Provider Business Mailing Address
First Line	:	1760 PRAIRIE AVE STE 100
Second Line	:
City	:	CHEYENNE
State	:	WY
Zip	:	82009-4833
Country	:	US
Telephone Number	:	307-263-4022
Fax Number	:	307-263-4023

Provider Business Practice Location Address
First Line	:	1760 PRAIRIE AVE STE 100
Second Line	:
City	:	CHEYENNE
State	:	WY
Zip	:	82009-4833
Country	:	US
Telephone Number	:	307-263-4022
Fax Number	:	307-263-4023

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

Provider Enumeration Date	:	12/06/2005
Last Update Date	:	11/11/2022

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