1922112374 NPI number — UNIVERSITY OF WYOMING STUDENT HEALTH SERVICE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922112374 NPI number — UNIVERSITY OF WYOMING STUDENT HEALTH SERVICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNIVERSITY OF WYOMING STUDENT HEALTH SERVICE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922112374
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 E. UNIVERSITY AVE
Provider Second Line Business Mailing Address:
DEPT. 3068
Provider Business Mailing Address City Name:
LARAMIE
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82071
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-766-2130
Provider Business Mailing Address Fax Number:
307-766-2711

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 E. UNIVERSITY AVE
Provider Second Line Business Practice Location Address:
DEPT. 3068
Provider Business Practice Location Address City Name:
LARAMIE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82071
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-766-2130
Provider Business Practice Location Address Fax Number:
307-766-2711
Provider Enumeration Date:
08/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BENDER
Authorized Official First Name:
MARY
Authorized Official Middle Name:
BETH
Authorized Official Title or Position:
M.D./DIRECTOR
Authorized Official Telephone Number:
307-766-2130

Provider Taxonomy Codes

  • Taxonomy code: 261QS1000X , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 107362102 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 107362103 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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