Basic Information
| Provider Information | |||||||||
| NPI: | 1649560764 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EGLESTON | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 428 S DURBIN ST | ||||||||
| Address2: | STE 104 | ||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826012818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073374284 | ||||||||
| FaxNumber: | 3074620922 | ||||||||
| Practice Location | |||||||||
| Address1: | 2761 COMMERCIAL WAY | ||||||||
| Address2: | |||||||||
| City: | ROCK SPRINGS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 829014753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073823064 | ||||||||
| FaxNumber: | 3073823303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2011 | ||||||||
| LastUpdateDate: | 05/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA630 | WY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 6306798-1206 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.