Basic Information
| Provider Information | |||||||||
| NPI: | 1043206485 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMOTHERS | ||||||||
| FirstName: | LANE | ||||||||
| MiddleName: | LESTER | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 419 S WASHINGTON ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826012951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3075774220 | ||||||||
| FaxNumber: | 3072350931 | ||||||||
| Practice Location | |||||||||
| Address1: | 419 S WASHINGTON ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826012951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3075774220 | ||||||||
| FaxNumber: | 3072350931 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | X | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 6580A | WY | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0575159 | 05 | IA | MEDICAID | 308892 | 01 | WY | BLUE CROSS BLUE SHIELD | OTHER | 0069853 | 05 | MT | MEDICAID | 97383848 | 05 | CO | MEDICAID | 8359358 | 05 | WA | MEDICAID |