Provider Demographics
NPI:1134297310
Name:MOSSBROOK, SANDRA SLADE (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:SLADE
Last Name:MOSSBROOK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4251 VALLEY GREEN CIRCLE
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-5453
Mailing Address - Country:US
Mailing Address - Phone:307-856-5600
Mailing Address - Fax:
Practice Address - Street 1:8204 STATE HIGHWAY 789
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-2941
Practice Address - Country:US
Practice Address - Phone:307-335-6716
Practice Address - Fax:307-335-6991
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3296A208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
F48351Medicare UPIN