Provider Demographics
NPI:1942443536
Name:PLATTE RIVER FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:PLATTE RIVER FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GRUWELL
Authorized Official - Suffix:
Authorized Official - Credentials:FNPC
Authorized Official - Phone:307-577-7737
Mailing Address - Street 1:1900 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2747
Mailing Address - Country:US
Mailing Address - Phone:307-577-7737
Mailing Address - Fax:307-577-0049
Practice Address - Street 1:1900 E 1ST ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2747
Practice Address - Country:US
Practice Address - Phone:307-577-7737
Practice Address - Fax:307-577-0049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-12
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY19507.318363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY128539400Medicaid
WYW22584Medicare Oscar/Certification