Healthcare Provider Details

I. General information

NPI: 1962718692
Provider Name (Legal Business Name): VETERANS AFFAIRS MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2010
Last Update Date: 08/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5709 EDUCATION DR APARTMENT 307
CHEYENNE WY
82009-3951
US

IV. Provider business mailing address

5709 EDUCATION DR APARTMENT 307
CHEYENNE WY
82009-3951
US

V. Phone/Fax

Practice location:
  • Phone: 307-760-4867
  • Fax:
Mailing address:
  • Phone: 307-760-4867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. KELLY ANN ROBERTSON
Title or Position: PHARMACY TECHNICIAN
Credential: CPHT, B.S
Phone: 307-760-4867