Provider Demographics
NPI:1134220783
Name:RILEY, MARK O (PA-C)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:O
Last Name:RILEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:720 LINDSAY LN
Mailing Address - Street 2:STE C
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-4103
Mailing Address - Country:US
Mailing Address - Phone:307-578-1955
Mailing Address - Fax:307-578-1957
Practice Address - Street 1:720 LINDSAY LN
Practice Address - Street 2:STE C
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-4103
Practice Address - Country:US
Practice Address - Phone:307-578-1955
Practice Address - Fax:307-578-1957
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WY140363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY315013OtherBLUE CROSS BLUE SHIELD
WY753143209OtherWIN HEALTH
WY612315900OtherOWCP
WYR04486Medicare UPIN
WY753143209OtherWIN HEALTH