Basic Information
| Provider Information | |||||||||
| NPI: | 1972546851 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TRENT | ||||||||
| FirstName: | STEPHAN | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1522 E A ST | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826012217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072336000 | ||||||||
| FaxNumber: | 3074731284 | ||||||||
| Practice Location | |||||||||
| Address1: | 1522 E A ST | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826012217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072336000 | ||||||||
| FaxNumber: | 3074731284 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 04/09/2012 | ||||||||
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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 | 207Q00000X | 6669A | WY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1172816-00 | 05 | WY | MEDICAID |