Basic Information
| Provider Information | |||||||||
| NPI: | 1376532952 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIRKSEN | ||||||||
| FirstName: | LAWRENCE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 449 MOUNTAIN VIEW ST | ||||||||
| Address2: | |||||||||
| City: | POWELL | ||||||||
| State: | WY | ||||||||
| PostalCode: | 824352232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077544559 | ||||||||
| FaxNumber: | 3077547733 | ||||||||
| Practice Location | |||||||||
| Address1: | 777 AVENUE H | ||||||||
| Address2: | |||||||||
| City: | POWELL | ||||||||
| State: | WY | ||||||||
| PostalCode: | 824352260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077542267 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 5566A | WY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 306684 | 01 | WY | BLUE CROSS BLUE SHIELD | OTHER | 0012064 | 05 | MT | MEDICAID |