Provider Demographics
NPI:1336720101
Name:PELLOQUIN, REGAN
Entity type:Individual
Prefix:
First Name:REGAN
Middle Name:
Last Name:PELLOQUIN
Suffix:
Gender:F
Credentials:
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 20970
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82003-7020
Mailing Address - Country:US
Mailing Address - Phone:307-996-4777
Mailing Address - Fax:307-773-8013
Practice Address - Street 1:2600 E 18TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5511
Practice Address - Country:US
Practice Address - Phone:307-633-7382
Practice Address - Fax:307-633-7202
Is Sole Proprietor?:No
Enumeration Date:2021-04-14
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY18298A2084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program