Organization
PAS WYOMING
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARK SPARKS JR. (DIRECTOR)
(307) 460-0507
Entity
Organization
Contact information
Practice address
1465 N 4TH ST STE 111, LARAMIE, WY 82072-2066
(307) 460-0507
Mailing address
PO BOX 1630, LARAMIE, WY 82073-1630
(307) 460-0507
Taxonomy
Speciality
Code
Description
License number
State
251B00000X
Case Management Agency
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
149132601
—
WY
Enumeration date
11/08/2018
Last updated
11/08/2018
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