Basic Information
| Provider Information | |||||||||
| NPI: | 1255538096 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RIVERTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825013230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078566530 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1001 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RIVERTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825013230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078566530 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2007 | ||||||||
| LastUpdateDate: | 09/29/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 01063733A | IN | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 8042A | WY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 200868510 | 05 | IN | MEDICAID | P00459733 | 01 | IN | RR MEDICARE | OTHER |