Provider Demographics
NPI:1801181730
Name:PROFESSIONAL PATHOLOGY OF WYOMING
Entity Type:Organization
Organization Name:PROFESSIONAL PATHOLOGY OF WYOMING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:R
Authorized Official - Last Name:CHRISTIANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-577-2198
Mailing Address - Street 1:1233 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2926
Mailing Address - Country:US
Mailing Address - Phone:307-577-2198
Mailing Address - Fax:419-866-5453
Practice Address - Street 1:1233 E 2ND ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2926
Practice Address - Country:US
Practice Address - Phone:307-577-2198
Practice Address - Fax:419-866-5453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-20
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY131615000Medicaid
WYW24183Medicare PIN