Basic Information
| Provider Information | |||||||||
| NPI: | 1679513816 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JARVIS | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 AVENUE H | ||||||||
| Address2: | |||||||||
| City: | POWELL | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077547257 | ||||||||
| FaxNumber: | 3077547744 | ||||||||
| Practice Location | |||||||||
| Address1: | 777 AVENUE H | ||||||||
| Address2: | |||||||||
| City: | POWELL | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077547257 | ||||||||
| FaxNumber: | 3077547744 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 08/11/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | 39980 | WI | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | 39980 | WI | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 32457500 | 05 | WI | MEDICAID |