Provider Demographics
NPI:1992047682
Name:WESTFALL, NILS CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:NILS
Middle Name:CHARLES
Last Name:WESTFALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-0428
Mailing Address - Country:US
Mailing Address - Phone:307-739-4818
Mailing Address - Fax:307-739-4866
Practice Address - Street 1:555 E BROADWAY AVE STE 204
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8640
Practice Address - Country:US
Practice Address - Phone:307-739-4818
Practice Address - Fax:307-739-4866
Is Sole Proprietor?:No
Enumeration Date:2013-03-21
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY13186A2084P0804X
CODR.00600442084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY156592300Medicaid
CO028869OtherKAISER COMMERCIAL NUMBER