MEDICARE: TOTAL FAMILY HEALTH, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	17189.0261	WY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	312190	OTHER		BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1083806111
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TOTAL FAMILY HEALTH, PC

Provider Business Mailing Address
First Line	:	2620 COMMERCIAL WAY
Second Line	:	SUITE 051
City	:	ROCK SPRINGS
State	:	WY
Zip	:	82901-4755
Country	:	US
Telephone Number	:	307-382-2080
Fax Number	:	307-382-5099

Provider Business Practice Location Address
First Line	:	2620 COMMERCIAL WAY
Second Line	:	SUITE 051
City	:	ROCK SPRINGS
State	:	WY
Zip	:	82901-4755
Country	:	US
Telephone Number	:	307-382-2080
Fax Number	:	307-382-5099

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LAURA J HEITZ
Credential	:	NP
Telephone Number	:	307-382-2080

Provider Enumeration Date	:	08/13/2007
Last Update Date	:	01/25/2010

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