Healthcare Provider Details

I. General information

NPI: 1780667808
Provider Name (Legal Business Name): LAWRENCE G GILL III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 03/07/2023
Certification Date: 03/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 W 5TH ST, STE 210
SHERIDAN WY
82801-2752
US

IV. Provider business mailing address

1333 W. 5TH ST, STE 110
SHERIDAN WY
82801-2752
US

V. Phone/Fax

Practice location:
  • Phone: 307-672-2522
  • Fax: 307-672-3732
Mailing address:
  • Phone: 307-672-2522
  • Fax: 307-672-3732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number3578A
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number3578A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: