MEDICARE: LAWRENCE G WAYBURN M.D.

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
1	2085R0202X	Diagnostic Radiology Physician	MD2007-0243	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	1891790192	OTHER	NPI
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891790192
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAWRENCE G WAYBURN M.D.

Provider Business Mailing Address
First Line	:	2 BIG BEAR PL
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87508
Country	:	US
Telephone Number	:	989-928-2397
Fax Number	:	505-471-4388

Provider Business Practice Location Address
First Line	:	2 BIG BEAR PL
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87508
Country	:	US
Telephone Number	:	989-928-2397
Fax Number	:	505-471-4388

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2005
Last Update Date	:	06/10/2016

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