Provider Demographics
NPI:1710279757
Name:SPROSTY, MICHAEL JASON (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JASON
Last Name:SPROSTY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 POWDERHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-7324
Mailing Address - Country:US
Mailing Address - Phone:307-286-3457
Mailing Address - Fax:
Practice Address - Street 1:4600 POWDERHOUSE RD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-7324
Practice Address - Country:US
Practice Address - Phone:307-286-3457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-10
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT652363A00000X
NY015663363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant