Basic Information
| Provider Information | |||||||||
| NPI: | 1598773368 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEALEY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | P. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 E. 17TH STREET | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820014797 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077777911 | ||||||||
| FaxNumber: | 3076343510 | ||||||||
| Practice Location | |||||||||
| Address1: | 820 E 17TH ST | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820014714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077777911 | ||||||||
| FaxNumber: | 3076343510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 11/19/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 5105A | WY | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207Q00000X | 5105A | WY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 108354600 | 05 | WY | MEDICAID |