Provider Demographics
NPI:1316011562
Name:STATE OF WYOMING
Entity Type:Organization
Organization Name:STATE OF WYOMING
Other - Org Name:WYOMING STATE HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:
Authorized Official - Last Name:BARKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-444-0721
Mailing Address - Street 1:PO BOX 177
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82931-0177
Mailing Address - Country:US
Mailing Address - Phone:307-444-0839
Mailing Address - Fax:307-789-7373
Practice Address - Street 1:251 YELLOWSTONE RIVER DR
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-5340
Practice Address - Country:US
Practice Address - Phone:307-444-0839
Practice Address - Fax:307-789-7373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY15163208D00000X, 283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes283Q00000XHospitalsPsychiatric Hospital
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1316011562OtherNATIONAL PROVIDER IDENTIFIER
WY534001Medicare PIN