Provider Demographics
NPI:1801889456
Name:WHEELER, LARAMIE L (DO)
Entity type:Individual
Prefix:DR
First Name:LARAMIE
Middle Name:L
Last Name:WHEELER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2410 E 25TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7549
Mailing Address - Country:US
Mailing Address - Phone:208-557-0200
Mailing Address - Fax:208-542-5080
Practice Address - Street 1:2410 E 25TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-557-0200
Practice Address - Fax:208-542-5080
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMR0836390200000X
IDO-0426207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807243000Medicaid