Healthcare Provider Details

I. General information

NPI: 1831184548
Provider Name (Legal Business Name): DEPALMA PEDIATRICS DBA EVANSTON PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 FEATHER WAY
EVANSTON WY
82930-9227
US

IV. Provider business mailing address

195 FEATHER WAY
EVANSTON WY
82930-9227
US

V. Phone/Fax

Practice location:
  • Phone: 307-789-1102
  • Fax: 307-789-9273
Mailing address:
  • Phone: 307-789-1102
  • Fax: 307-789-9273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number7258A
License Number StateWY

VIII. Authorized Official

Name: MRS. CATHERINE MARIE DEPALMA
Title or Position: PEDIATRICS
Credential: MD
Phone: 307-789-1102