1619228186 NPI number — ROBERT DANIEL WOOD

Table of content: ROBERT DANIEL WOOD (NPI 1619228186)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619228186 NPI number — ROBERT DANIEL WOOD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOOD
Provider First Name:
ROBERT
Provider Middle Name:
DANIEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WOOD
Provider Other First Name:
DAN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP-C
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1619228186
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 428
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
83001-0428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-739-7696
Provider Business Mailing Address Fax Number:
307-739-4877

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5235 HHR RANCH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILSON
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
83014-9210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-739-7696
Provider Business Practice Location Address Fax Number:
307-739-4877
Provider Enumeration Date:
09/25/2012

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: 363LF0000X , with the licence number:  1417 , 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: 141422400 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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