Basic Information
| Provider Information | |||||||||
| NPI: | 1205822442 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 419 S WASHINGTON ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826012951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3075774220 | ||||||||
| FaxNumber: | 3072350931 | ||||||||
| Practice Location | |||||||||
| Address1: | 419 S WASHINGTON ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826012951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3075774220 | ||||||||
| FaxNumber: | 3072350931 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 3032A | WY | X | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | 3032A | WY | X | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0575134 | 05 | IA | MEDICAID | 0069887 | 05 | MT | MEDICAID | 301490 | 01 | WY | BLUE CROSS BLUE SHIELD | OTHER | 8359374 | 05 | WA | MEDICAID | 78282241 | 05 | CO | MEDICAID |