Provider Demographics
NPI:1679534432
Name:CONWAY, LARS T (MD)
Entity Type:Individual
Prefix:
First Name:LARS
Middle Name:T
Last Name:CONWAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4940
Mailing Address - Street 2:625 E BROADWAY
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-4940
Mailing Address - Country:US
Mailing Address - Phone:307-733-6418
Mailing Address - Fax:307-734-0885
Practice Address - Street 1:625 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8642
Practice Address - Country:US
Practice Address - Phone:307-733-6418
Practice Address - Fax:307-734-0885
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27443207ZC0500X, 207ZP0101X
IDM-12068207ZP0102X
WY9164A207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN220007425OtherRR MEDICARE
MN936780200Medicaid
MN03069C0OtherBCBS
MN03069C0OtherBCBS
MN220000045Medicare ID - Type Unspecified