Basic Information
| Provider Information | |||||||||
| NPI: | 1811084080 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1073 | ||||||||
| Address2: | |||||||||
| City: | BIG PINEY | ||||||||
| State: | WY | ||||||||
| PostalCode: | 831131073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072763238 | ||||||||
| FaxNumber: | 3072764707 | ||||||||
| Practice Location | |||||||||
| Address1: | 2761 COMMERCIAL WAY | ||||||||
| Address2: | |||||||||
| City: | ROCK SPRINGS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073823064 | ||||||||
| FaxNumber: | 3073823033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2018 | ||||||||
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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 | 363A00000X | 204 | WY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | MA0478633 | 01 | WY | DEA | OTHER | 313592 | 01 | WY | BLUE CROSS BLUE SHIELD WY | OTHER | 114736600 | 05 | WY | MEDICAID |