Healthcare Provider Details

I. General information

NPI: 1871623124
Provider Name (Legal Business Name): POPO AGIE WOMEN'S CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 03/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1460 MAIN ST
LANDER WY
82520-2657
US

IV. Provider business mailing address

1460 MAIN ST
LANDER WY
82520-2657
US

V. Phone/Fax

Practice location:
  • Phone: 307-332-2223
  • Fax:
Mailing address:
  • Phone: 307-332-2223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number9192.0137
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9192.0137
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number9192.0137
License Number StateWY

VIII. Authorized Official

Name: MRS. RUTH C ZEBROSKI
Title or Position: PRESIDENT
Credential: WHNP-C
Phone: 307-332-2223