Provider Demographics
NPI:1407425184
Name:COURSON, GREGORY (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:COURSON
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:764 N PINE ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072-2455
Mailing Address - Country:US
Mailing Address - Phone:614-562-4617
Mailing Address - Fax:
Practice Address - Street 1:255 N 30TH ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-5140
Practice Address - Country:US
Practice Address - Phone:307-755-4580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-17
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY47996363LA2200X, 363LG0600X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology