Provider Demographics
NPI:1972781524
Name:MARK P MENOLASCINO MD PC
Entity type:Organization
Organization Name:MARK P MENOLASCINO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:P
Authorized Official - Last Name:MENOLASCINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-732-1039
Mailing Address - Street 1:PO BOX 4816
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-4816
Mailing Address - Country:US
Mailing Address - Phone:307-732-1039
Mailing Address - Fax:307-732-1041
Practice Address - Street 1:5235 HHR RANCH ROAD
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:WY
Practice Address - Zip Code:83014
Practice Address - Country:US
Practice Address - Phone:307-732-1039
Practice Address - Fax:307-732-1041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6730A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY118685000Medicaid
WIH95913Medicare UPIN
WY118685000Medicaid