Provider Demographics
NPI:1457003139
Name:PADILLA, DESERIEE
Entity Type:Individual
Prefix:
First Name:DESERIEE
Middle Name:
Last Name:PADILLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-4202
Mailing Address - Country:US
Mailing Address - Phone:307-212-7708
Mailing Address - Fax:307-352-8148
Practice Address - Street 1:3000 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-4202
Practice Address - Country:US
Practice Address - Phone:307-212-7708
Practice Address - Fax:307-352-8148
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-24
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY49265363L00000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner