Provider Demographics
NPI:1992782619
Name:HORSLEY, MARILYN KAY (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:KAY
Last Name:HORSLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-2708
Mailing Address - Country:US
Mailing Address - Phone:307-675-5555
Mailing Address - Fax:307-675-5599
Practice Address - Street 1:916 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-2708
Practice Address - Country:US
Practice Address - Phone:307-672-6451
Practice Address - Fax:307-672-1704
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY180363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7705130Medicaid
WY180OtherSTATE LICENCE
00941001OtherGROUP #
NE166389462Medicaid
TX0193235OtherMEDICA NUMBER
WY1000484900Medicaid
MT000405665Medicaid
WY1116MH98MOtherCONTROLLED SUBSTANCE REGI
311273OtherBCBS INDIVIDUAL #
NE8302457118-13Medicaid
NE8302457118-13Medicaid
NE166389462Medicaid
00941001OtherGROUP #