Healthcare Provider Details

I. General information

NPI: 1629019351
Provider Name (Legal Business Name): LARRY J HATTEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 02/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3235 SPARKS RD SUITE 200
CHEYENNE WY
82001-6158
US

IV. Provider business mailing address

4003 RAWLINS ST.
CHEYENNE WY
82001-1800
US

V. Phone/Fax

Practice location:
  • Phone: 307-638-8975
  • Fax: 307-634-9267
Mailing address:
  • Phone: 307-638-8975
  • Fax: 307-634-9267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number4666A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: