Healthcare Provider Details

I. General information

NPI: 1508857350
Provider Name (Legal Business Name): FLOYD B NUTTALL PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2005
Last Update Date: 08/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 S 6TH ST
WORLAND WY
82401-3339
US

IV. Provider business mailing address

151 S 6TH ST
WORLAND WY
82401-3339
US

V. Phone/Fax

Practice location:
  • Phone: 307-347-8262
  • Fax: 307-347-8265
Mailing address:
  • Phone: 307-347-8262
  • Fax: 307-347-8265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberTL480
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: