Provider Demographics
NPI:1033358981
Name:POMMER, MARK B (EDM)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:B
Last Name:POMMER
Suffix:
Gender:M
Credentials:EDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6887
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-6887
Mailing Address - Country:US
Mailing Address - Phone:307-699-1030
Mailing Address - Fax:
Practice Address - Street 1:925 SMITH LN
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-699-1030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-17
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYCSSP04103TM1800X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities