Basic Information
| Provider Information | |||||||||
| NPI: | 1851363212 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETTIPIECE | ||||||||
| FirstName: | KURT | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 AVENUE H | ||||||||
| Address2: | |||||||||
| City: | POWELL | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077547257 | ||||||||
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| Practice Location | |||||||||
| Address1: | 777 AVENUE H | ||||||||
| Address2: | |||||||||
| City: | POWELL | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077547257 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 07/02/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 3709AWY | WY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 116973400 | 05 | WY | MEDICAID | AP3166661 | 01 | WY | DEA | OTHER | 3709AWY | 01 | WY | WY MEDICAL LICENSE # | OTHER | 427KP93 | 01 | WY | WY CONTROLLED SUBSTANCE # | OTHER |