Basic Information
| Provider Information | |||||||||
| NPI: | 1578671186 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WARREN | ||||||||
| FirstName: | WAYNE | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 419 S WASHINGTON ST | ||||||||
| Address2: | STE 201 | ||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826012951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3348210466 | ||||||||
| FaxNumber: | 3348214682 | ||||||||
| Practice Location | |||||||||
| Address1: | 419 S WASHINGTON ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826012951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072330250 | ||||||||
| FaxNumber: | 3072375421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 06/01/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 10439A | WY | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | W2600 | 01 | WY | PTAN | OTHER |