Provider Demographics
NPI:1659045383
Name:PROFESSIONAL PATHOLOGY OF WYOMING
Entity Type:Organization
Organization Name:PROFESSIONAL PATHOLOGY OF WYOMING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:R
Authorized Official - Last Name:CHRISTIANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-337-1670
Mailing Address - Street 1:111 S JEFFERSON ST STE 150
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2654
Mailing Address - Country:US
Mailing Address - Phone:307-277-2041
Mailing Address - Fax:
Practice Address - Street 1:5400 SUTLIVE ST STE 3
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4721
Practice Address - Country:US
Practice Address - Phone:770-972-4845
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty