Basic Information
| Provider Information | |||||||||
| NPI: | 1932362985 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | ETMAN | ||||||||
| FirstName: | AMR | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3000 COLLEGE DR | ||||||||
| Address2: | |||||||||
| City: | ROCK SPRINGS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 829014202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073621861 | ||||||||
| FaxNumber: | 3073621277 | ||||||||
| Practice Location | |||||||||
| Address1: | 541 SUNSET LN STE 301 | ||||||||
| Address2: | |||||||||
| City: | CULPEPER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 227013979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5408254557 | ||||||||
| FaxNumber: | 5408254566 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2008 | ||||||||
| LastUpdateDate: | 11/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 8029A | WY | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VG0400X | 0101257200 | VA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 830306180 | 01 | WY | TAX ID | OTHER | 8029A | 01 | WY | WYOMING LICENSE# | OTHER | 124781600 | 05 | WY | MEDICAID | 0101257200 | 01 | VA | LICENSE | OTHER | 307009 | 01 | WY | CHWHC MEDICARE | OTHER |