Provider Demographics
NPI:1699316430
Name:SHIDEMAN, JEFFREY ANTON (DNP, NP-C)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ANTON
Last Name:SHIDEMAN
Suffix:
Gender:M
Credentials:DNP, NP-C
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 STE 110
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-2752
Mailing Address - Country:US
Mailing Address - Phone:307-675-2650
Mailing Address - Fax:307-675-2651
Practice Address - Street 1:61 S GOULD ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-6304
Practice Address - Country:US
Practice Address - Phone:307-675-2690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-02
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY44709363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY154294000Medicaid