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General NPI Number Information
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NPI Number | 1164804480
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Entity Type | Organization
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Legal Business Name | A WYOMING PAIN CLINIC P C
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Dates
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Enumeration Date | 06/23/2015
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Last Update Date | 01/23/2024
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Provider Practice Location Address
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Address Line | 3100 W LAKEWAY RD SUITE 3
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City | GILLETTE
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State | WY
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Zip | 82718-6372
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Country | US
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Telephone | 307-696-1475
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Fax |
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Provider Business Mailing Address
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Address Line | 8101 STONE CREST DR
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City | GILLETTE
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State | WY
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Zip | 82718-4006
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Country | US
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Telephone | 307-696-1475
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Fax |
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Authorized Official
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Title or Position | PROVIDER
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Name | JOHN L. MANSELL
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Credential | MD
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Telephone | 307-696-2996
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 7144A
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License Number State | WY
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Taxonomy #2
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Taxonomy Code | 261QP3300X
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Taxonomy Name | Pain Clinic/Center
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License Number | 7144A
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License Number State | WY
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Taxonomy #3
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Taxonomy Code | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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License Number | 7144A
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License Number State | WY
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