Basic Information
Provider Information | |||||||||
NPI: | 1699316430 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHIDEMAN | ||||||||
FirstName: | JEFFREY | ||||||||
MiddleName: | ANTON | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DNP, NP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1333 W 5TH ST STE 110 | ||||||||
Address2: |   | ||||||||
City: | SHERIDAN | ||||||||
State: | WY | ||||||||
PostalCode: | 828012752 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3076752650 | ||||||||
FaxNumber: | 3076752651 | ||||||||
Practice Location | |||||||||
Address1: | 61 S GOULD ST | ||||||||
Address2: |   | ||||||||
City: | SHERIDAN | ||||||||
State: | WY | ||||||||
PostalCode: | 828016304 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3076752690 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/02/2019 | ||||||||
LastUpdateDate: | 10/13/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/13/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 44709 | WY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 154294000 | 05 | WY |   | MEDICAID |