Basic Information
| Provider Information | |||||||||
| NPI: | 1780027953 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TETON PATHOLOGY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4940 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 830014940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128016060 | ||||||||
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| Practice Location | |||||||||
| Address1: | 625 E BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 830018642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077333636 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2013 | ||||||||
| LastUpdateDate: | 04/08/2013 | ||||||||
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| AuthorizedOfficialLastName: | CONWAY | ||||||||
| AuthorizedOfficialFirstName: | LARS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6128016060 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 9164A | WY | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.