Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207V00000X | Obstetrician & Gynecologist | 4198A | WY |
NPI | 1003805698 |
---|---|
Provider Name | Robert F Ellis |
First Address | Powell, WY 82435-2232 |
Second Address | Powell, WY 82435-2212 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/10/2005 |
Last Update Date | 19/10/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
313903 | BLUE CROSS BLUE SHIELD (01) | WY |
E69793 | (02) | WY |