Provider Demographics
NPI:1972535227
Name:MANSELL, JOHN L (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:L
Last Name:MANSELL
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 1:3100 W LAKEWAY RD
Mailing Address - Street 2:STE 3
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-6373
Mailing Address - Country:US
Mailing Address - Phone:307-696-2996
Mailing Address - Fax:307-670-8250
Practice Address - Street 1:3100 W LAKEWAY RD
Practice Address - Street 2:SUITE 3
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-6372
Practice Address - Country:US
Practice Address - Phone:307-696-2996
Practice Address - Fax:307-670-8250
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2016-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036096773207L00000X
WY7144A207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E97712Medicare UPIN
IL610900/L62484Medicare PIN
032433OtherHEALTH ALLIANCE