Provider Demographics
NPI:1750311072
Name:LUSK MEDICAL CLINIC
Entity Type:Organization
Organization Name:LUSK MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:OTTERSBACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-334-2900
Mailing Address - Street 1:PO BOX 930
Mailing Address - Street 2:
Mailing Address - City:LUSK
Mailing Address - State:WY
Mailing Address - Zip Code:82225-0930
Mailing Address - Country:US
Mailing Address - Phone:307-334-2900
Mailing Address - Fax:307-334-2904
Practice Address - Street 1:119 WEST 3RD STREET
Practice Address - Street 2:
Practice Address - City:LUSK
Practice Address - State:WY
Practice Address - Zip Code:82225
Practice Address - Country:US
Practice Address - Phone:307-334-2900
Practice Address - Fax:307-334-2904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health