Provider Demographics
NPI:1316071145
Name:PAYNE, JOHN C (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:PAYNE
Suffix:
Gender:M
Credentials:DO
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:307-739-7618
Mailing Address - Fax:307-734-0077
Practice Address - Street 1:555 E BROADWAY AVE STE 211
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8640
Practice Address - Country:US
Practice Address - Phone:307-739-7618
Practice Address - Fax:307-734-0077
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6651A2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY117561100Medicaid
F02138Medicare UPIN
WY311631OtherBC BS WYOMING