Healthcare Provider Details

I. General information

NPI: 1205884715
Provider Name (Legal Business Name): GARY MIKESELL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 07/22/2020
Certification Date: 07/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 3RD ST
RAWLINS WY
82301-5612
US

IV. Provider business mailing address

300 3RD ST
RAWLINS WY
82301-5612
US

V. Phone/Fax

Practice location:
  • Phone: 307-324-8494
  • Fax:
Mailing address:
  • Phone: 307-324-8494
  • Fax: 307-324-8496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12467A
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberGM012991
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: