Healthcare Provider Details

I. General information

NPI: 1407015308
Provider Name (Legal Business Name): ROBYN CARROLL YETKA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2008
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 W FOX FARM RD
CHEYENNE WY
82007-2360
US

IV. Provider business mailing address

714 W FOX FARM RD
CHEYENNE WY
82007-2360
US

V. Phone/Fax

Practice location:
  • Phone: 130-777-8783
  • Fax: 130-777-8257
Mailing address:
  • Phone: 130-777-8783
  • Fax: 130-777-8257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number118
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: