Provider Demographics
NPI:1770982530
Name:BYNUM, ALISHA (LAC, MSOM)
Entity type:Individual
Prefix:
First Name:ALISHA
Middle Name:
Last Name:BYNUM
Suffix:
Gender:F
Credentials:LAC, MSOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-3338
Mailing Address - Country:US
Mailing Address - Phone:307-856-8800
Mailing Address - Fax:307-856-8808
Practice Address - Street 1:604 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-3338
Practice Address - Country:US
Practice Address - Phone:307-856-8800
Practice Address - Fax:307-856-8808
Is Sole Proprietor?:No
Enumeration Date:2014-08-18
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACU 0001990171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist