Provider Demographics
NPI:1710684543
Name:CHILDREN 1ST PEDIATRICS ASSOCIATES OF WYOMING, LLC
Entity Type:Organization
Organization Name:CHILDREN 1ST PEDIATRICS ASSOCIATES OF WYOMING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:KNUDSON-JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-333-3690
Mailing Address - Street 1:732 W COLLINS DR
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2327
Mailing Address - Country:US
Mailing Address - Phone:307-333-6940
Mailing Address - Fax:888-964-2162
Practice Address - Street 1:732 W COLLINS DR
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2327
Practice Address - Country:US
Practice Address - Phone:307-333-6940
Practice Address - Fax:888-964-2162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-13
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1518124114Medicaid
WY1083704803Medicaid