Provider Demographics
NPI:1427172279
Name:PAYNE, HOLLY GAIL (DO)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:GAIL
Last Name:PAYNE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:GAIL
Other - Last Name:BREUNINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 8729
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-8729
Mailing Address - Country:US
Mailing Address - Phone:307-733-8070
Mailing Address - Fax:307-733-8077
Practice Address - Street 1:555 E. BROADWAY
Practice Address - Street 2:SUITE 211
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-733-8070
Practice Address - Fax:307-733-8077
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6948A208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Not Answered2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E64289Medicare UPIN