Basic Information
| Provider Information | |||||||||
| NPI: | 1417952391 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NOE | ||||||||
| FirstName: | GARY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 189 | ||||||||
| Address2: | |||||||||
| City: | LYMAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 829370189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077873313 | ||||||||
| FaxNumber: | 3077873312 | ||||||||
| Practice Location | |||||||||
| Address1: | 107 N MAIN ST. | ||||||||
| Address2: | |||||||||
| City: | LYMAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077873313 | ||||||||
| FaxNumber: | 3077873312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 04/17/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 3898A | WY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 308484 | 01 | TN | BCBS | OTHER | 103803600 | 05 | WY | MEDICAID |