Provider Demographics
NPI:1871916544
Name:JEFFERY W. EDSTROM
Entity type:Organization
Organization Name:JEFFERY W. EDSTROM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MEIER
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:307-674-5123
Mailing Address - Street 1:PO BOX 767
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-0767
Mailing Address - Country:US
Mailing Address - Phone:307-674-5123
Mailing Address - Fax:307-674-5230
Practice Address - Street 1:1524 W 5TH ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-2707
Practice Address - Country:US
Practice Address - Phone:307-672-7874
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-30
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY23492.0828367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1164427274Medicaid