Basic Information
| Provider Information | |||||||||
| NPI: | 1790388213 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TETON PEDIATRICS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4182 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 830014182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077336520 | ||||||||
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| Practice Location | |||||||||
| Address1: | 555 E BROADWAY AVE STE 202 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 830018640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077336520 | ||||||||
| FaxNumber: | 3077333216 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2020 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
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| AuthorizedOfficialLastName: | HARDENBROOK | ||||||||
| AuthorizedOfficialFirstName: | JACQUELIN | ||||||||
| AuthorizedOfficialMiddleName: | FOSS | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3077336520 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.