Healthcare Provider Details

I. General information

NPI: 1215944301
Provider Name (Legal Business Name): ALPHA FAMILY MEDICINE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 09/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 CLEVELAND AVE
CHEYENNE WY
82001-6700
US

IV. Provider business mailing address

1202 CLEVELAND AVE
CHEYENNE WY
82001-6700
US

V. Phone/Fax

Practice location:
  • Phone: 307-632-6403
  • Fax: 307-632-6426
Mailing address:
  • Phone: 307-632-6403
  • Fax: 307-632-6426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5374A
License Number StateWY

VIII. Authorized Official

Name: KATHLEEN M GATES
Title or Position: OWNER
Credential: F.N.P.C
Phone: 307-632-6403