Provider Demographics
NPI:1023110640
Name:PETERSON, LARS E (MD)
Entity type:Individual
Prefix:MR
First Name:LARS
Middle Name:E
Last Name:PETERSON
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 1:320 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-3822
Mailing Address - Country:US
Mailing Address - Phone:307-399-2883
Mailing Address - Fax:
Practice Address - Street 1:255 N 30TH ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-5140
Practice Address - Country:US
Practice Address - Phone:307-742-2141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-03
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6962A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY119117900Medicaid
WYW24571Medicare PIN
I00959Medicare UPIN
WY9916Medicare ID - Type Unspecified