Provider Demographics
NPI:1790721306
Name:WAECKERLIN, RON W (MD)
Entity Type:Individual
Prefix:
First Name:RON
Middle Name:W
Last Name:WAECKERLIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 HOUSE AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3177
Mailing Address - Country:US
Mailing Address - Phone:307-634-9238
Mailing Address - Fax:307-778-3665
Practice Address - Street 1:2301 HOUSE AVE STE 108
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3177
Practice Address - Country:US
Practice Address - Phone:307-634-9238
Practice Address - Fax:307-778-3665
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYE12250207ZC0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E12250Medicare UPIN