NPIMap

Organization Active NPI

Mountain Sage Holistic Clinic, LLC

  • Primary Care Nurse Practitioner
  • Dubois, WY
National Provider Identifier
1376924621
Registry record updated Jun 12, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Nurse PractitionerTaxonomy code 363LP2300X
License
33105.1295 Issued in WY
Legal business name
MOUNTAIN SAGE HOLISTIC CLINIC, LLC
Practice address
1428 Warm Springs Dr
Dubois, WY 82513-1428
Phone
(307) 455-2807
Fax
(307) 455-2809
NPI assigned
Jun 12, 2015
Last updated
Jun 12, 2015By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 12, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Martin P Baum
Title
Business Manager
Phone
(307) 455-2807

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Primary Care Nurse Practitioner 363LP2300X 33105.1295 WY Primary

Addresses

Primary practice location

1428 Warm Springs Dr
Dubois, WY 82513-1428

Mailing address

1428 Warm Springs Dr
Dubois, WY 82513-1428
Phone (307) 455-2807

Other identifiers 1

IdentifierTypeStateIssuer
136115500MedicaidWY

National Provider Directory

National Provider Directory

Interoperability endpoints

  • FHIR API: https://api.platform.athenahealth.com/9630/brand/1/csg/1/fhir/r4

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1434067200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1434067200000",
    "number": "1376924621",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1428 WARM SPRINGS DR",
            "city": "DUBOIS",
            "state": "WY",
            "postal_code": "825131428",
            "telephone_number": "307-455-2807",
            "fax_number": "307-455-2809"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1428 WARM SPRINGS DR",
            "city": "DUBOIS",
            "state": "WY",
            "postal_code": "825131428",
            "telephone_number": "307-455-2807",
            "fax_number": "307-455-2809"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MOUNTAIN SAGE HOLISTIC CLINIC, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-06-12",
        "last_updated": "2015-06-12",
        "status": "A",
        "authorized_official_last_name": "BAUM",
        "authorized_official_first_name": "MARTIN",
        "authorized_official_middle_name": "P",
        "authorized_official_title_or_position": "BUSINESS MANAGER",
        "authorized_official_telephone_number": "307-455-2807"
    },
    "taxonomies": [
        {
            "code": "363LP2300X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Primary Care",
            "state": "WY",
            "license": "33105.1295",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "136115500",
            "state": "WY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Dubois, WY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 12, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.