Healthcare Provider Details

I. General information

NPI: 1942969787
Provider Name (Legal Business Name): MEMORIAL HOSPITAL OF LARAMIE COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2021
Last Update Date: 07/03/2026
Certification Date: 07/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 E 23RD ST
CHEYENNE WY
82001-3748
US

IV. Provider business mailing address

PO BOX 20970
CHEYENNE WY
82003-7020
US

V. Phone/Fax

Practice location:
  • Phone: 307-633-7955
  • Fax: 307-633-7018
Mailing address:
  • Phone: 307-633-7955
  • Fax: 307-633-7018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BRAD WHITE
Title or Position: ADMINISTRATOR OF REVENUE
Credential:
Phone: 307-633-6198