1760654651 NPI number — REBECCA ASHLEY SJOSTROM M.D.

Table of content: REBECCA ASHLEY SJOSTROM M.D. (NPI 1760654651)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760654651 NPI number — REBECCA ASHLEY SJOSTROM M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SJOSTROM
Provider First Name:
REBECCA
Provider Middle Name:
ASHLEY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760654651
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/04/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
970 W BROADWAY STE E
Provider Second Line Business Mailing Address:
#121
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
83001-6403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-699-6801
Provider Business Mailing Address Fax Number:
307-733-6912

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
945 W BROADWAY AVE
Provider Second Line Business Practice Location Address:
STE 202
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
83001-8217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-699-6801
Provider Business Practice Location Address Fax Number:
307-733-6912
Provider Enumeration Date:
03/31/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  8081 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: 48707 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: 13178A , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 48707 . This is a "COLORADO MEDICAL LICENSE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: 13178A . This is a "WY MEDICAL LICENSE" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 8081 . This is a "ALASKA MEDICAL LICENSE" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".