Provider Demographics
NPI:1366719718
Name:BIDONDE FAMILY PRACTICE, LLC
Entity type:Organization
Organization Name:BIDONDE FAMILY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:K
Authorized Official - Last Name:HAM
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:307-684-1444
Mailing Address - Street 1:107 W HESSE ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:WY
Mailing Address - Zip Code:82834-1501
Mailing Address - Country:US
Mailing Address - Phone:307-684-1444
Mailing Address - Fax:307-684-0999
Practice Address - Street 1:107 W HESSE ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:WY
Practice Address - Zip Code:82834-1501
Practice Address - Country:US
Practice Address - Phone:307-684-1444
Practice Address - Fax:307-684-0999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-29
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY23899-0963363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY126725600Medicaid