Provider Demographics
NPI:1720772551
Name:MYRICK, RUSTIN (FNP)
Entity type:Individual
Prefix:
First Name:RUSTIN
Middle Name:
Last Name:MYRICK
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 LANE 12
Mailing Address - Street 2:
Mailing Address - City:LOVELL
Mailing Address - State:WY
Mailing Address - Zip Code:82431-9537
Mailing Address - Country:US
Mailing Address - Phone:307-548-5200
Mailing Address - Fax:307-548-5678
Practice Address - Street 1:1115 LANE 12
Practice Address - Street 2:
Practice Address - City:LOVELL
Practice Address - State:WY
Practice Address - Zip Code:82431-9537
Practice Address - Country:US
Practice Address - Phone:307-548-5200
Practice Address - Fax:307-548-5678
Is Sole Proprietor?:No
Enumeration Date:2023-06-05
Last Update Date:2025-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY52597363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily