Healthcare Provider Details

I. General information

NPI: 1700635489
Provider Name (Legal Business Name): MITCHELL THOMAE MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2024
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 E 18TH ST
CHEYENNE WY
82001-4775
US

IV. Provider business mailing address

821 E 18TH ST
CHEYENNE WY
82001-4775
US

V. Phone/Fax

Practice location:
  • Phone: 307-777-7911
  • Fax:
Mailing address:
  • Phone: 307-777-7911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberSG
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberTL9257
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: