MEDICARE: WYOMING RANGE MEDICAL PC

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	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	313591	OTHER	WY	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1871680041
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WYOMING RANGE MEDICAL PC

Provider Business Mailing Address
First Line	:	PO BOX 1479
Second Line	:
City	:	ROCK SPRINGS
State	:	WY
Zip	:	82902-1479
Country	:	US
Telephone Number	:	307-382-3064
Fax Number	:	307-382-3303

Provider Business Practice Location Address
First Line	:	2761 COMMERCIAL WAY
Second Line	:
City	:	ROCK SPRINGS
State	:	WY
Zip	:	82901-4753
Country	:	US
Telephone Number	:	307-382-3064
Fax Number	:	307-382-3303

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	KANDACE FERNANDEZ
Credential	:
Telephone Number	:	307-382-3064

Provider Enumeration Date	:	10/06/2006
Last Update Date	:	09/11/2018

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Directions to “WYOMING RANGE MEDICAL PC ” Practice Location

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