Provider Demographics
NPI:1205147576
Name:LEDOUX, AMY NICOLE (PAC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:NICOLE
Last Name:LEDOUX
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 N BROOKS ST
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-3801
Mailing Address - Country:US
Mailing Address - Phone:307-672-8941
Mailing Address - Fax:307-672-7461
Practice Address - Street 1:1662 S SHERIDAN AVE
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-5644
Practice Address - Country:US
Practice Address - Phone:307-672-8941
Practice Address - Fax:307-672-7461
Is Sole Proprietor?:No
Enumeration Date:2010-07-01
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY131365700Medicaid
WYW24045Medicare PIN