Provider Demographics
NPI:1508857350
Name:NUTTALL, FLOYD B (PAC)
Entity Type:Individual
Prefix:MR
First Name:FLOYD
Middle Name:B
Last Name:NUTTALL
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:WORLAND
Mailing Address - State:WY
Mailing Address - Zip Code:82401-3339
Mailing Address - Country:US
Mailing Address - Phone:307-347-8262
Mailing Address - Fax:307-347-8265
Practice Address - Street 1:151 S 6TH ST
Practice Address - Street 2:
Practice Address - City:WORLAND
Practice Address - State:WY
Practice Address - Zip Code:82401-3339
Practice Address - Country:US
Practice Address - Phone:307-347-8262
Practice Address - Fax:307-347-8265
Is Sole Proprietor?:No
Enumeration Date:2005-11-01
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYTL480363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S89439Medicare UPIN