Provider Demographics
NPI:1164804480
Name:A WYOMING PAIN CLINIC P C
Entity Type:Organization
Organization Name:A WYOMING PAIN CLINIC P C
Other - Org Name:POWDER RIVER PAIN CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MANSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-696-2996
Mailing Address - Street 1:8101 STONE CREST DR
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-4006
Mailing Address - Country:US
Mailing Address - Phone:307-696-1475
Mailing Address - Fax:
Practice Address - Street 1:3100 W LAKEWAY RD
Practice Address - Street 2:SUITE 3
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-6372
Practice Address - Country:US
Practice Address - Phone:307-696-1475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY7144A207L00000X, 207LP2900X, 261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPainGroup - Multi-Specialty