Provider Demographics
NPI:1871623124
Name:POPO AGIE WOMEN'S CLINIC, INC
Entity type:Organization
Organization Name:POPO AGIE WOMEN'S CLINIC, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:C
Authorized Official - Last Name:ZEBROSKI
Authorized Official - Suffix:
Authorized Official - Credentials:WHNP-C
Authorized Official - Phone:307-332-2223
Mailing Address - Street 1:1460 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-2657
Mailing Address - Country:US
Mailing Address - Phone:307-332-2223
Mailing Address - Fax:
Practice Address - Street 1:1460 MAIN ST
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-2657
Practice Address - Country:US
Practice Address - Phone:307-332-2223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY9192.0137363LA2200X, 363LF0000X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY116652200Medicaid
WY309073Medicare ID - Type UnspecifiedGROUP NUMBERS
WY116652200Medicaid