MEDICARE: PARVANAE PENTICO

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	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1245774421
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PARVANAE PENTICO

Provider Business Mailing Address
First Line	:	350 CITY VIEW DR STE 206
Second Line	:
City	:	EVANSTON
State	:	WY
Zip	:	82930-5326
Country	:	US
Telephone Number	:	307-789-7915
Fax Number	:	307-789-6009

Provider Business Practice Location Address
First Line	:	350 CITY VIEW DR STE 206
Second Line	:
City	:	EVANSTON
State	:	WY
Zip	:	82930-5326
Country	:	US
Telephone Number	:	307-789-7915
Fax Number	:	307-789-6009

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/07/2016
Last Update Date	:	12/07/2016

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Directions to “ PARVANAE PENTICO ” Practice Location

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