Basic Information
| Provider Information | |||||||||
| NPI: | 1225361470 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARLSON | ||||||||
| FirstName: | LORI | ||||||||
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| Credential: | FNPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 20970 | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820037020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076337444 | ||||||||
| FaxNumber: | 3076345627 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 E 20TH ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820013885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076337444 | ||||||||
| FaxNumber: | 3076345627 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2009 | ||||||||
| LastUpdateDate: | 08/06/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 15471.1013 | WY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 12253614701 | 05 | WY | MEDICAID |