MEDICARE: INSTACARE CENTER OF WYOMING - WEST, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053877654
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INSTACARE CENTER OF WYOMING - WEST, INC

Provider Business Mailing Address
First Line	:	900 CY AVE
Second Line	:
City	:	CASPER
State	:	WY
Zip	:	82601-4174
Country	:	US
Telephone Number	:	307-266-1719
Fax Number	:	307-472-7150

Provider Business Practice Location Address
First Line	:	900 CY AVE
Second Line	:
City	:	CASPER
State	:	WY
Zip	:	82601-4174
Country	:	US
Telephone Number	:	307-266-1719
Fax Number	:	307-472-7150

Authorized Official
Title or Position	:	DIRECTOR
Name	:	NICOLETTE HANSON
Credential	:	DNP, FNP-BC
Telephone Number	:	307-266-1719

Provider Enumeration Date	:	02/19/2019
Last Update Date	:	07/02/2019

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