Provider Demographics
NPI:1952340200
Name:BLINN, LAWRENCE A (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:A
Last Name:BLINN
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 1:295 GARFIELD ST
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3121
Mailing Address - Country:US
Mailing Address - Phone:307-332-2357
Mailing Address - Fax:307-332-4276
Practice Address - Street 1:295 GARFIELD ST
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3121
Practice Address - Country:US
Practice Address - Phone:307-332-2357
Practice Address - Fax:307-332-4276
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC326382085R0202X
WY8030A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7916311Medicaid
NC16311OtherBCBS NC
WYW22071Medicare PIN
NC7916311Medicaid
NC2143002Medicare ID - Type Unspecified
NC2143002AMedicare ID - Type Unspecified