Provider Demographics
NPI:1194752634
Name:NIETHAMMER, THOMAS H (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:H
Last Name:NIETHAMMER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 W 5TH ST
Mailing Address - Street 2:STE 206
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801
Mailing Address - Country:US
Mailing Address - Phone:307-673-8383
Mailing Address - Fax:
Practice Address - Street 1:1333 W 5TH ST
Practice Address - Street 2:STE 206
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801
Practice Address - Country:US
Practice Address - Phone:307-673-8383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3508A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY302616OtherBLUE CROSS
WYA73037Medicare UPIN
WYW9292Medicare PIN