Provider Demographics
NPI:1659579191
Name:TRENETTE ANN LARSON MD PC
Entity Type:Organization
Organization Name:TRENETTE ANN LARSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRENETTE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-778-8437
Mailing Address - Street 1:10115 BRANDING IRON DR
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-8614
Mailing Address - Country:US
Mailing Address - Phone:307-778-8437
Mailing Address - Fax:307-778-8503
Practice Address - Street 1:10115 BRANDING IRON DR
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-8614
Practice Address - Country:US
Practice Address - Phone:307-778-8437
Practice Address - Fax:307-778-8503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-06
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3624207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY113966500Medicaid
WY116807000Medicaid
WYG03124Medicare UPIN
WY116807000Medicaid