Healthcare Provider Details

I. General information

NPI: 1962500611
Provider Name (Legal Business Name): JED CABRERA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 EAST 17TH STREET
CHEYENNE WY
82001-4797
US

IV. Provider business mailing address

820 EAST 17TH STREET
CHEYENNE WY
82001-4797
US

V. Phone/Fax

Practice location:
  • Phone: 307-632-2434
  • Fax: 307-634-9295
Mailing address:
  • Phone: 307-777-7911
  • Fax: 307-638-3616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number375
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: