Individual
JUSTIN GERALD TATTERSALL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
625 E BROADWAY AVE, JACKSON, WY 83001-8642
(307) 733-3636
Mailing address
PO BOX 9871, JACKSON, WY 83002-9871
(307) 413-0437
Taxonomy
Speciality
Code
Description
License number
State
163WR0006X
Registered Nurse First Assistant
Primary
30955
WY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
3074130437
NONE
—
Enumeration date
11/03/2017
Last updated
11/03/2017
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