Healthcare Provider Details

I. General information

NPI: 1477110617
Provider Name (Legal Business Name): MANASA JASTI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2019
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 HOUSE AVE STE 301
CHEYENNE WY
82001-3178
US

IV. Provider business mailing address

2301 HOUSE AVE STE 301
CHEYENNE WY
82001-3178
US

V. Phone/Fax

Practice location:
  • Phone: 307-637-1600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberTL9155
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: