Provider Demographics
NPI:1003384983
Name:PAS WYOMING
Entity Type:Organization
Organization Name:PAS WYOMING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SPARKS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:307-460-0507
Mailing Address - Street 1:PO BOX 1630
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82073-1630
Mailing Address - Country:US
Mailing Address - Phone:307-460-0507
Mailing Address - Fax:
Practice Address - Street 1:1465 N 4TH ST STE 111
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-2066
Practice Address - Country:US
Practice Address - Phone:307-460-0507
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY149132601Medicaid