Provider Demographics
NPI:1215944301
Name:ALPHA FAMILY MEDICINE, INC.
Entity type:Organization
Organization Name:ALPHA FAMILY MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:GATES
Authorized Official - Suffix:
Authorized Official - Credentials:FNPC
Authorized Official - Phone:307-632-6403
Mailing Address - Street 1:1202 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-6700
Mailing Address - Country:US
Mailing Address - Phone:307-632-6403
Mailing Address - Fax:307-632-6426
Practice Address - Street 1:1202 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-6700
Practice Address - Country:US
Practice Address - Phone:307-632-6403
Practice Address - Fax:307-632-6426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5374A207Q00000X
363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW20542Medicare ID - Type Unspecified