Basic Information
| Provider Information | |||||||||
| NPI: | 1912419623 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOENIG | ||||||||
| FirstName: | LORA | ||||||||
| MiddleName: | LEA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5000 BLACKMORE RD | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826093345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072336000 | ||||||||
| FaxNumber: | 3072336089 | ||||||||
| Practice Location | |||||||||
| Address1: | 1035 ROSE LN | ||||||||
| Address2: | |||||||||
| City: | RIVERTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825012291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072336000 | ||||||||
| FaxNumber: | 3072336089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2017 | ||||||||
| LastUpdateDate: | 01/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 20484 | WY | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 1792 | WY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 20484.1792 | WY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1912419623 | 05 | WY | MEDICAID |