Provider Demographics
NPI:1932231081
Name:ROWAN E TICHENOR MD PC
Entity type:Organization
Organization Name:ROWAN E TICHENOR MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROWAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:TICHENOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-266-2772
Mailing Address - Street 1:1119 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2905
Mailing Address - Country:US
Mailing Address - Phone:307-266-2772
Mailing Address - Fax:307-266-2076
Practice Address - Street 1:1119 E 3RD ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2905
Practice Address - Country:US
Practice Address - Phone:307-266-2772
Practice Address - Fax:307-266-2076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY2634A207ND0900X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW306951Medicare PIN