Provider Demographics
NPI:1891314514
Name:SHORT, DEVIN
Entity Type:Individual
Prefix:
First Name:DEVIN
Middle Name:
Last Name:SHORT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2910
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82931-2910
Mailing Address - Country:US
Mailing Address - Phone:307-789-4224
Mailing Address - Fax:
Practice Address - Street 1:190 OVERTHRUST ROAD
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930
Practice Address - Country:US
Practice Address - Phone:307-789-4224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-13
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker