Provider Demographics
NPI:1700127040
Name:WYOMING MEDICAL CENTER CLINICAL LAB
Entity Type:Organization
Organization Name:WYOMING MEDICAL CENTER CLINICAL LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:LARAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-747-4000
Mailing Address - Street 1:2901 N CENTRAL AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
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:307-577-7201
Practice Address - Fax:307-577-7862
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WYOMING MEDICAL CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-12
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY53D0519997291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory