Provider Demographics
NPI:1992787980
Name:VIPPERMAN, JOHN R (PAC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:VIPPERMAN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 BIG HORN AVE
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-9208
Mailing Address - Country:US
Mailing Address - Phone:307-578-1955
Mailing Address - Fax:307-578-1979
Practice Address - Street 1:3030 BIG HORN AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-9208
Practice Address - Country:US
Practice Address - Phone:307-578-1955
Practice Address - Fax:307-578-1979
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT306363AM0700X
WY207363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT810511516021OtherEBMS
WY117477100Medicaid
WY3110550OtherBLUE CROSS
MT0439535Medicaid
MT000094353OtherBLUE CROSS BUTTE MT
MT0439535Medicaid
MT011000804Medicare PIN
MT011003208Medicare PIN
MT000094353OtherBLUE CROSS BUTTE MT
WY3110550OtherBLUE CROSS
MT810511516021OtherEBMS