Provider Demographics
NPI:1144284506
Name:ALLISON, ARCHIE BROOKS (MD)
Entity type:Individual
Prefix:
First Name:ARCHIE
Middle Name:BROOKS
Last Name:ALLISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BROOKS
Other - Middle Name:
Other - Last Name:ALLISON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2100 W SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-2274
Mailing Address - Country:US
Mailing Address - Phone:307-857-3590
Mailing Address - Fax:307-857-3553
Practice Address - Street 1:2100 W SUNSET DR
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-2274
Practice Address - Country:US
Practice Address - Phone:307-857-3590
Practice Address - Fax:307-857-3553
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY4404A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYD73490Medicare UPIN
WY307862Medicare ID - Type Unspecified