Provider Demographics
NPI:1790708568
Name:PRINCE, MARK D (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:PRINCE
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:PO BOX 780
Mailing Address - Street 2:
Mailing Address - City:LUSK
Mailing Address - State:WY
Mailing Address - Zip Code:82225-0780
Mailing Address - Country:US
Mailing Address - Phone:307-334-4000
Mailing Address - Fax:
Practice Address - Street 1:921 S BALLANCEE AVE
Practice Address - Street 2:
Practice Address - City:LUSK
Practice Address - State:WY
Practice Address - Zip Code:82225
Practice Address - Country:US
Practice Address - Phone:307-334-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY2848A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY82009A032OtherWPS TRIWEST
WY308045OtherBLUE SHIELD
WY00356OtherWINHEALTH PARTNERS
WY110187400OtherRAILROAD MEDICARE
WY114388300Medicaid
WY308045OtherBLUE SHIELD
WYB03782Medicare UPIN