Provider Demographics
NPI:1184800674
Name:WILLOW CREEK FAMILY MEDICINE, P.C.
Entity type:Organization
Organization Name:WILLOW CREEK FAMILY MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:E
Authorized Official - Last Name:HATTEL
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:307-638-8975
Mailing Address - Street 1:4003 RAWLINS ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-1800
Mailing Address - Country:US
Mailing Address - Phone:307-638-8975
Mailing Address - Fax:307-634-9267
Practice Address - Street 1:4003 RAWLINS ST.
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-1800
Practice Address - Country:US
Practice Address - Phone:307-638-8975
Practice Address - Fax:307-634-9267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY16129.0890363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY125575400Medicaid
DN1175OtherRAILROAD MEDICARE - PALMETTO GBA
21772Medicare PIN