Provider Demographics
NPI:1881246551
Name:WYOMING MEDICAL WELLNESS CENTER PC
Entity type:Organization
Organization Name:WYOMING MEDICAL WELLNESS CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIELA
Authorized Official - Middle Name:S
Authorized Official - Last Name:GERARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD , PHD, FMCP
Authorized Official - Phone:307-670-9200
Mailing Address - Street 1:801 EAST 4TH STREET
Mailing Address - Street 2:SUITE 17
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-4061
Mailing Address - Country:US
Mailing Address - Phone:307-670-9200
Mailing Address - Fax:307-257-7531
Practice Address - Street 1:801 EAST 4TH STREET
Practice Address - Street 2:SUITE 17
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-4061
Practice Address - Country:US
Practice Address - Phone:307-670-9200
Practice Address - Fax:307-257-7531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-12
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty