Provider Demographics
NPI:1922091859
Name:CLEGG, PAMELA P (MD)
Entity type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:P
Last Name:CLEGG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:PAMELA
Other - Middle Name:P
Other - Last Name:ROOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:707 SHERIDAN AVE
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-3409
Mailing Address - Country:US
Mailing Address - Phone:307-578-1850
Mailing Address - Fax:307-587-6041
Practice Address - Street 1:1008 CODY AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-4118
Practice Address - Country:US
Practice Address - Phone:307-578-1850
Practice Address - Fax:307-587-6041
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5112A207ZP0007X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0007XAllopathic & Osteopathic PhysiciansPathologyMolecular Genetic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTP00399845Medicare PIN
F78945Medicare UPIN