Basic Information
| Provider Information | |||||||||
| NPI: | 1780667808 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GILL | ||||||||
| FirstName: | LAWRENCE | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1333 W. 5TH ST, STE 110 | ||||||||
| Address2: | |||||||||
| City: | SHERIDAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828012752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076722522 | ||||||||
| FaxNumber: | 3076723732 | ||||||||
| Practice Location | |||||||||
| Address1: | 1333 W 5TH ST, STE 210 | ||||||||
| Address2: | |||||||||
| City: | SHERIDAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828012752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076722522 | ||||||||
| FaxNumber: | 3076723732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 03/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 3578A | WY | N | Other Service Providers | Specialist | 207V00000X | 3578A | WY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 97253 | 05 | MT | MEDICAID | 110391100 | 05 | WY | MEDICAID | 3578A | 01 | WY | STATE LICENSE NUMBER | OTHER | AG1163687 | 01 | WY | DEA NUMBER | OTHER |