MEDICARE: BRENDA R VANCE PA-C

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	363A00000X	Physician Assistant	188	WY

General Provider Information

NPI Number	:	1871593301
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENDA R VANCE PA-C

Provider Business Mailing Address
First Line	:	2566 JEFFERSON ST
Second Line	:
City	:	LARAMIE
State	:	WY
Zip	:	82070-6565
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 E UNIVERSITY AVE
Second Line	:	UNIVERSITY OF WYOMING STUDENT HEALTH SER. DEPT. 3068
City	:	LARAMIE
State	:	WY
Zip	:	82071-2000
Country	:	US
Telephone Number	:	307-776-2139
Fax Number	:	307-776-2711

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2005
Last Update Date	:	07/08/2007

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