Provider Demographics
NPI:1609849199
Name:FARRELL, ARTHUR J (PAC)
Entity Type:Individual
Prefix:
First Name:ARTHUR
Middle Name:J
Last Name:FARRELL
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 1:5307 YELLOWSTONE RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-4736
Mailing Address - Country:US
Mailing Address - Phone:307-632-7677
Mailing Address - Fax:
Practice Address - Street 1:4136 LARAMIE ST
Practice Address - Street 2:SUITE B
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-1969
Practice Address - Country:US
Practice Address - Phone:307-637-2800
Practice Address - Fax:307-637-2867
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY121860300Medicaid
WY315527OtherBSWY
WY314333OtherBLUE CROSS BLUE SHIELD
WY315527OtherBSWY
WYS62288Medicare UPIN
WY121860300Medicaid