Healthcare Provider Details

I. General information

NPI: 1073976320
Provider Name (Legal Business Name): SONIA SCHUPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2016
Last Update Date: 04/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 SOUTH FRANKLIN
PINEDALE WY
82941
US

IV. Provider business mailing address

PO BOX 955
PINEDALE WY
82941-0955
US

V. Phone/Fax

Practice location:
  • Phone: 307-367-6306
  • Fax:
Mailing address:
  • Phone: 307-367-3617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberOT-647
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: