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NPI Code Detail

MEDICARE: MR. LARS E PETERSON MD

MEDICARE: MR. LARS E PETERSON MD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207R00000XInternal Medicine Physician6962AWY

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1023110640
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. LARS E PETERSON MD
Provider Business Mailing Address
First Line : 320 S 7TH ST
Second Line :
City : LARAMIE
State : WY
Zip : 82070-3822
Country : US
Telephone Number : 307-399-2883
Fax Number :
Provider Business Practice Location Address
First Line : 255 N 30TH ST
Second Line :
City : LARAMIE
State : WY
Zip : 82072-5140
Country : US
Telephone Number : 307-742-2141
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/03/2006
Last Update Date : 10/31/2012

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