Provider Demographics
NPI:1154562791
Name:ETTER, THOMAS H (DO)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:H
Last Name:ETTER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:THOMAS
Other - Middle Name:
Other - Last Name:ETTER LLC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:902 BLACKBURN ST
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-8494
Mailing Address - Country:US
Mailing Address - Phone:307-296-1355
Mailing Address - Fax:307-586-5464
Practice Address - Street 1:902 BLACKBURN ST
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-8494
Practice Address - Country:US
Practice Address - Phone:307-296-1355
Practice Address - Fax:307-586-5464
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-11
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYTL2094208600000X
MO2006003130208600000X
WY9334A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO28058OtherGHP
MO921792OtherHEALTHLINK INC
MO1154562791Medicaid
MO622086OtherANTHEM BLUECROSS BLUESHIELD
MO9847314OtherAETNA
MO12740475OtherPHCS
MO12740475OtherMULTIPLAN
MO3032610OtherUNITED HEALTHCARE
MO12740475OtherPHCS
MO3032610OtherUNITED HEALTHCARE
MO1154562791Medicaid