Provider Demographics
NPI:1730688839
Name:PEDRO, ANTOINETTE MARIE
Entity type:Individual
Prefix:MS
First Name:ANTOINETTE
Middle Name:MARIE
Last Name:PEDRO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1989
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-0240
Mailing Address - Country:US
Mailing Address - Phone:307-857-9455
Mailing Address - Fax:307-333-0450
Practice Address - Street 1:10269 HIGHWAY 789
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-8829
Practice Address - Country:US
Practice Address - Phone:307-857-9455
Practice Address - Fax:307-333-0450
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker