Provider Demographics
NPI:1932337631
Name:BULLOCK, NYASHA ONIKA (MD)
Entity Type:Individual
Prefix:
First Name:NYASHA
Middle Name:ONIKA
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NYASHA
Other - Middle Name:ONIKA
Other - Last Name:MORNIX
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:111 S JEFFERSON ST
Mailing Address - Street 2:STE 150
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2665
Mailing Address - Country:US
Mailing Address - Phone:307-337-1670
Mailing Address - Fax:
Practice Address - Street 1:111 S JEFFERSON ST
Practice Address - Street 2:STE 150
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2665
Practice Address - Country:US
Practice Address - Phone:307-337-1670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY10604A207ZC0500X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology