Organization Name: | STATE OF WYOMING |
NPI Number: | 1316011562 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | PAUL MULLENAX (BUSINESS MANAGER) |
Mailing Address: | 831 State Highway 150 S Evanston |
State: | WY US |
Postal Code: | 829305340 |
Phone Number: | 3077893464 |
Fax Number: | 3077897373 |
NPI Enumeration Date: | 11/20/2006 |
NPI Last Update Date: | 11/12/2015 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 208D00000X |
License Number: | 15163 |
Healthcare Provider Taxonomy: (Secondary) | N |
State: | WY |
Taxonomy Type: | Allopathic & Osteopathic Physicians |
Taxonomy Classification: | General Practice |
Taxonomy Specialization: | |
Taxonomy Definition: |