Provider Demographics
NPI:1891748703
Name:PICKRELL, JOHN WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WILLIAM
Last Name:PICKRELL
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 1:1230 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2704
Mailing Address - Country:US
Mailing Address - Phone:307-266-3174
Mailing Address - Fax:307-261-6713
Practice Address - Street 1:1230 E 1ST ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2704
Practice Address - Country:US
Practice Address - Phone:307-266-3174
Practice Address - Fax:307-261-6713
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6881A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY312640OtherBLUE SHIELD
WYP00091628OtherRAILROAD MEDICARE
WY118594200Medicaid
WY9702OtherBCBS
WYW9702Medicare PIN
WY9702OtherBCBS
WY118594200Medicaid