1396815809 NPI number — TOM A NACHTIGAL MD

Table of content: TOM A NACHTIGAL MD (NPI 1396815809)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396815809 NPI number — TOM A NACHTIGAL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NACHTIGAL
Provider First Name:
TOM
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NACHTIGAL
Provider Other First Name:
TOM
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD FACS PC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1396815809
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/31/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LARAMIE
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82073-0103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-760-8468
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3125 E GRAND AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
LARAMIE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82070-5137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-745-8442
Provider Business Practice Location Address Fax Number:
307-742-0036
Provider Enumeration Date:
11/09/2006

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: 208600000X , with the licence number:  4490A , 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: 116885100 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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