Provider Demographics
NPI:1235282120
Name:WYOMING NEUROLOGY P.C.
Entity Type:Organization
Organization Name:WYOMING NEUROLOGY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:J
Authorized Official - Last Name:FARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:307-432-0335
Mailing Address - Street 1:2301 HOUSE AVE
Mailing Address - Street 2:STE 203
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3176
Mailing Address - Country:US
Mailing Address - Phone:307-432-0335
Mailing Address - Fax:307-432-0341
Practice Address - Street 1:2301 HOUSE AVE
Practice Address - Street 2:STE 203
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3176
Practice Address - Country:US
Practice Address - Phone:307-432-0335
Practice Address - Fax:307-432-0341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY159020190363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1156560 01Medicaid
WYS39328Medicare UPIN
WY1156560 01Medicaid