Provider Demographics
NPI:1932889482
Name:WYOMING HEART AND VASCULAR CENTER LLC
Entity Type:Organization
Organization Name:WYOMING HEART AND VASCULAR CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CARDIOLOGIST/MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MANSOUR
Authorized Official - Middle Name:
Authorized Official - Last Name:KHADDR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:412-626-0143
Mailing Address - Street 1:1204 HILLTOP DR STE 106
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-5861
Mailing Address - Country:US
Mailing Address - Phone:307-522-5555
Mailing Address - Fax:888-819-5155
Practice Address - Street 1:1204 HILLTOP DR STE 106
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-5861
Practice Address - Country:US
Practice Address - Phone:307-522-5555
Practice Address - Fax:888-819-5155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-20
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty