Provider Demographics
NPI:1558657650
Name:UNIVERSITY OF WYOMING
Entity Type:Organization
Organization Name:UNIVERSITY OF WYOMING
Other - Org Name:WYOMING FAMILY PRACTICE
Other - Org Type:Other Name
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BETH
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROBITAILLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-234-6161
Mailing Address - Street 1:1522 E A ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2217
Mailing Address - Country:US
Mailing Address - Phone:307-234-6161
Mailing Address - Fax:307-473-1824
Practice Address - Street 1:1522 E A ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2217
Practice Address - Country:US
Practice Address - Phone:307-234-6161
Practice Address - Fax:307-234-7033
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF WYOMING
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-06-27
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY207Q00000X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY531818Medicare Oscar/Certification
WYW4370998Medicare PIN