Provider Demographics
NPI:1811285059
Name:WYOMING FAMILY PRACTICE CLINIC
Entity type:Organization
Organization Name:WYOMING FAMILY PRACTICE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBITAILLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-234-6161
Mailing Address - Street 1:1522 E A ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2217
Mailing Address - Country:US
Mailing Address - Phone:307-234-6161
Mailing Address - Fax:307-234-7033
Practice Address - Street 1:1522 E A ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2217
Practice Address - Country:US
Practice Address - Phone:307-234-6161
Practice Address - Fax:307-234-7033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-20
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY390200000X261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care