Healthcare Provider Details

I. General information

NPI: 1992787980
Provider Name (Legal Business Name): JOHN R VIPPERMAN PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 BIG HORN AVE
CODY WY
82414-9208
US

IV. Provider business mailing address

3030 BIG HORN AVE
CODY WY
82414-9208
US

V. Phone/Fax

Practice location:
  • Phone: 307-578-1955
  • Fax: 307-578-1979
Mailing address:
  • Phone: 307-578-1955
  • Fax: 307-578-1979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number306
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number207
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: