Provider Demographics
NPI:1265087993
Name:PONY EXPRESS PEDIATRICS, LLC
Entity type:Organization
Organization Name:PONY EXPRESS PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/APRN CPNP-PC
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTA
Authorized Official - Middle Name:JAYLEEN
Authorized Official - Last Name:KOVACHEVICH
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:321-313-3595
Mailing Address - Street 1:2076 PAINTED SKY RD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-9196
Mailing Address - Country:US
Mailing Address - Phone:321-313-3595
Mailing Address - Fax:
Practice Address - Street 1:1307 CROOK AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5412
Practice Address - Country:US
Practice Address - Phone:321-313-3595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PONY EXPRESS PEDIATRICS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016218600Medicaid