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General NPI Number Information
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NPI Number | 1437842390
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Entity Type | Organization
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Legal Business Name | GRAND AVE FAMILY MEDICINE
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Dates
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Enumeration Date | 05/29/2023
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Last Update Date | 05/29/2023
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Provider Practice Location Address
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Address Line | 3236 E GRAND AVE STE D
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City | LARAMIE
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State | WY
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Zip | 82070-5100
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Country | US
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Telephone | 970-231-3498
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Fax |
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Provider Business Mailing Address
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Address Line | 3236 E GRAND AVE STE D
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City | LARAMIE
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State | WY
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Zip | 82070-5100
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Country | US
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Telephone | 970-231-3498
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JOHN JACOBS III
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Credential | NP
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Telephone | 970-231-3498
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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