Healthcare Provider Details

I. General information

NPI: 1386627362
Provider Name (Legal Business Name): PHILIP MARION SHARP MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 10/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 E 23RD ST
CHEYENNE WY
82001-3748
US

IV. Provider business mailing address

PO BOX 20970
CHEYENNE WY
82003-7020
US

V. Phone/Fax

Practice location:
  • Phone: 307-633-6080
  • Fax: 307-432-3106
Mailing address:
  • Phone: 307-773-8012
  • Fax: 307-633-7676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number2371A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: