Basic Information
| Provider Information | |||||||||
| NPI: | 1265548424 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VILLANO | ||||||||
| FirstName: | JEREMI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 517 | ||||||||
| Address2: | |||||||||
| City: | SUNDANCE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 827290517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072832476 | ||||||||
| FaxNumber: | 3072832255 | ||||||||
| Practice Location | |||||||||
| Address1: | 713 OAK STREET | ||||||||
| Address2: | |||||||||
| City: | SUNDANCE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072832476 | ||||||||
| FaxNumber: | 3072832489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2541A | WY | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2740 | SD | N | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.