Provider Demographics
NPI:1366439598
Name:CAMPBELL, CAROL A (FNP/PA-C)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:A
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:FNP/PA-C
Other - Prefix:MISS
Other - First Name:CAROL
Other - Middle Name:ANN
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:821 EAST 18TH STREET
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-4797
Mailing Address - Country:US
Mailing Address - Phone:307-632-2434
Mailing Address - Fax:307-634-3510
Practice Address - Street 1:820 EAST 17TH STREET
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4797
Practice Address - Country:US
Practice Address - Phone:307-632-2434
Practice Address - Fax:307-634-3510
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
WY25536 0932363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAR91295Medicare UPIN