Provider Demographics
NPI:1447364245
Name:MENOLASCINO, MICHAEL JAMES (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:MENOLASCINO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-0428
Mailing Address - Country:US
Mailing Address - Phone:307-739-7696
Mailing Address - Fax:307-739-4877
Practice Address - Street 1:5245 HHR RANCH ROAD
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:WY
Practice Address - Zip Code:83014-9210
Practice Address - Country:US
Practice Address - Phone:307-739-7696
Practice Address - Fax:307-739-4877
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY4440A207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY103312300Medicaid
WY21623OtherMEDICARE PTAN
WY103312300Medicaid
WY116969600Medicaid