Provider Demographics
NPI:1174870554
Name:EPIX ANESTHESIA OF CHEYENNE, PC
Entity type:Organization
Organization Name:EPIX ANESTHESIA OF CHEYENNE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:PRUITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:720-810-2955
Mailing Address - Street 1:3949 HOLCOMB BRIDGE RD
Mailing Address - Street 2:STE 300
Mailing Address - City:PEACHTREE CORNERS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-2294
Mailing Address - Country:US
Mailing Address - Phone:678-580-1349
Mailing Address - Fax:770-559-1231
Practice Address - Street 1:2301 HOUSE AVE
Practice Address - Street 2:STE 300
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3176
Practice Address - Country:US
Practice Address - Phone:844-793-1380
Practice Address - Fax:770-559-1231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-06
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY207L00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW24943Medicare PIN