Basic Information
Provider Information | |||||||||
NPI: | 1962553578 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LENGFELDER | ||||||||
FirstName: | VALERIE | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CORDERO | ||||||||
OtherFirstName: | VALERIE | ||||||||
OtherMiddleName: | J | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 777 AVENUE H | ||||||||
Address2: |   | ||||||||
City: | POWELL | ||||||||
State: | WY | ||||||||
PostalCode: | 824352260 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3077547257 | ||||||||
FaxNumber: | 3077541231 | ||||||||
Practice Location | |||||||||
Address1: | 777 AVENUE H | ||||||||
Address2: |   | ||||||||
City: | POWELL | ||||||||
State: | WY | ||||||||
PostalCode: | 824352260 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3077547257 | ||||||||
FaxNumber: | 3077541231 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/12/2007 | ||||||||
LastUpdateDate: | 09/30/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 7876A | WY | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | MD00043851 | WA | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 8425845 | 05 | WA |   | MEDICAID |