Provider Demographics
NPI:1578949533
Name:AMARIS SPANG
Entity Type:Organization
Organization Name:AMARIS SPANG
Other - Org Name:RN
Other - Org Type:Other Name
Authorized Official - Title/Position:NURS
Authorized Official - Prefix:
Authorized Official - First Name:AMARIS
Authorized Official - Middle Name:E
Authorized Official - Last Name:SPANG
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:406-679-3157
Mailing Address - Street 1:1008 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501
Mailing Address - Country:US
Mailing Address - Phone:406-679-3157
Mailing Address - Fax:307-332-9446
Practice Address - Street 1:1008 E MAIN ST
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-3730
Practice Address - Country:US
Practice Address - Phone:406-679-3157
Practice Address - Fax:307-332-9446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-31
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY35707261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY105726000Medicaid
WY105726000Medicaid