Provider Demographics
NPI:1629019351
Name:HATTEL, LARRY J (MD)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:J
Last Name:HATTEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4003 RAWLINS ST.
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-1800
Mailing Address - Country:US
Mailing Address - Phone:307-638-8975
Mailing Address - Fax:307-634-9267
Practice Address - Street 1:3235 SPARKS RD
Practice Address - Street 2:SUITE 200
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-6158
Practice Address - Country:US
Practice Address - Phone:307-638-8975
Practice Address - Fax:307-634-9267
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY4666A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1629019351Medicaid
WYP00720533OtherRAILROAD MEDICARE - PALMETTO GBA
NE270123Medicare PIN
WYC77015Medicare UPIN
WY305634Medicare ID - Type Unspecified