Provider Demographics
NPI:1467566117
Name:MENOLASCINO, MARK P (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:P
Last Name:MENOLASCINO
Suffix:
Gender:M
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:PO BOX 4816
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-4816
Mailing Address - Country:US
Mailing Address - Phone:307-732-1039
Mailing Address - Fax:
Practice Address - Street 1:5235 HHR RANCH ROAD
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:WY
Practice Address - Zip Code:83014-0000
Practice Address - Country:US
Practice Address - Phone:307-732-1039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6730A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY118685000Medicaid
WY118685000Medicaid