MEDICARE: WYOBRASKA FAMILY PRACTICE LLC

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

General Provider Information

NPI Number	:	1174263040
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WYOBRASKA FAMILY PRACTICE LLC

Provider Business Mailing Address
First Line	:	2810 W B ST
Second Line	:
City	:	TORRINGTON
State	:	WY
Zip	:	82240-1940
Country	:	US
Telephone Number	:	307-537-5111
Fax Number	:

Provider Business Practice Location Address
First Line	:	2810 W B ST
Second Line	:
City	:	TORRINGTON
State	:	WY
Zip	:	82240-1940
Country	:	US
Telephone Number	:	307-537-5111
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. AARON RUTZ
Credential	:
Telephone Number	:	307-536-5111

Provider Enumeration Date	:	03/30/2022
Last Update Date	:	03/30/2022

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