Teton Dermatology LLC

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

Legal business name

TETON DERMATOLOGY LLC

Practice address

984 West Broadway
Suite 4
Jackson, WY 83001-0000

Phone

(307) 734-1800

Fax

(307) 734-5012

NPI assigned

May 21, 2010

Reactivated

Oct 7, 2021

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Gheorghe Pusta

Title

Executive Director

Phone

(512) 628-0465

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in WY

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Brittany Wilson Baker, MD

  • Dermatology Physician
  • Jackson, WY
  • NPI 1265653745
  Medicare reassignment Care Compare group NPD
• Jonathan Glenn Baker, M.D.

  • Dermatology Physician
  • Jackson, WY
  • NPI 1447233754
  Medicare reassignment Care Compare group NPD
• Jane G. Khoury, M.D.

  • Dermatology Physician
  • Ladera Ranch, CA
  • NPI 1245246214

  WY

  Medicare reassignment Care Compare group NPD
• Nathan S. Uebelhoer, D.O.

  • MOHS-Micrographic Surgery Physician
  • National City, CA
  • NPI 1659344513

  Dermatology, WY

  Medicare reassignment Care Compare group NPD
• Kelly N O'Connor

  • Dermatology Physician
  • Jackson, WY
  • NPI 1841849312
  Medicare reassignment Care Compare group
• Robin Sproule

  • Physician Assistant
  • Jackson, WY
  • NPI 1497154975
  Medicare reassignment Care Compare group

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1274400000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1726617600000",
    "number": "1194044750",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7300 RANCH RD. 2222, BLDG 1, STE 200",
            "city": "AUSTIN",
            "state": "TX",
            "postal_code": "78730",
            "telephone_number": "512-628-0465",
            "fax_number": "512-628-0468"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "984 WEST BROADWAY",
            "address_2": "SUITE 4",
            "city": "JACKSON",
            "state": "WY",
            "postal_code": "830010000",
            "telephone_number": "307-734-1800",
            "fax_number": "307-734-5012"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TETON DERMATOLOGY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-05-21",
        "last_updated": "2024-09-18",
        "certification_date": "2024-09-18",
        "deactivation_date": "2021-08-23",
        "reactivation_date": "2021-10-07",
        "status": "A",
        "authorized_official_last_name": "PUSTA",
        "authorized_official_first_name": "GHEORGHE",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "512-628-0465",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Teton County Hospital District (St Johns Medical Center)
• Teton County Hospital District (St. John's Pharmacy)
• Teton County Hospital District (St John's Medical Center Pharmacy)
• Teton County School District 1
• Teton Crest Counseling LLC
• Teton Hand Therapy LLC
• Teton Hand Therapy LLC
• Teton Internal Medicine PC
• Teton MRI (MRI of Jackson Hole)
• Teton Oral & Maxillofacial Surgery

• Dermatology Physician in Jackson, WY
• Providers in Jackson, WY by specialty
• Dermatology Physician in Wyoming

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 18, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.