Basic Information
| Provider Information | |||||||||
| NPI: | 1770198764 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF WYOMING | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1522 E A ST | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826012217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072336161 | ||||||||
| FaxNumber: | 3072347032 | ||||||||
| Practice Location | |||||||||
| Address1: | 1522 E A ST | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826012217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072336161 | ||||||||
| FaxNumber: | 3072347032 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2020 | ||||||||
| LastUpdateDate: | 09/15/2020 | ||||||||
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| AuthorizedOfficialLastName: | ROBITAILLE | ||||||||
| AuthorizedOfficialFirstName: | BETH | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CMO | ||||||||
| AuthorizedOfficialTelephone: | 3072346161 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 09/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.