Healthcare Provider Details

I. General information

NPI: 1609034131
Provider Name (Legal Business Name): VIRGINIA LOUISE TUBBS NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2008
Last Update Date: 06/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 S DURBIN ST STE 103
CASPER WY
82601-2829
US

IV. Provider business mailing address

3981 SWINGLE ACRES RD
CASPER WY
82604-4213
US

V. Phone/Fax

Practice location:
  • Phone: 307-265-2936
  • Fax: 307-265-6575
Mailing address:
  • Phone: 307-237-2564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number15067.0953
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: