Basic Information
| Provider Information | |||||||||
| NPI: | 1033271366 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RODDY | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 S 336TH ST | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980036328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538386180 | ||||||||
| FaxNumber: | 2538386418 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 COLLEGE DR | ||||||||
| Address2: | |||||||||
| City: | ROCK SPRINGS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 829015868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073528350 | ||||||||
| FaxNumber: | 3073528178 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 12/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 6643A | WY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 605960009 | 01 | WY | FBL | OTHER | 116306000 | 05 | WY | MEDICAID | 315393 | 01 | WY | BSWY | OTHER |