Provider Demographics
NPI:1629099312
Name:SURDAM, AMY R (NP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:R
Last Name:SURDAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:R
Other - Last Name:FORKNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NO
Mailing Address - Street 1:PO BOX 20170
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82003-7004
Mailing Address - Country:US
Mailing Address - Phone:307-635-5393
Mailing Address - Fax:307-635-2199
Practice Address - Street 1:433 E 19TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4643
Practice Address - Country:US
Practice Address - Phone:307-635-5393
Practice Address - Fax:307-635-2199
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY18161.0312363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY121544200Medicaid
WY313763OtherBLUE SHIELD
WYP00251860OtherRAILROAD MEDICARE
WY23339OtherWINHEALTH PARTNERS
WY82009A055OtherWPS TRIWEST
WY82009A055OtherWPS TRIWEST
WY20439Medicare ID - Type Unspecified