Provider Demographics
NPI:1538366075
Name:DIANE R EDWARDS
Entity type:Organization
Organization Name:DIANE R EDWARDS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-472-3769
Mailing Address - Street 1:915 S DAVID ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-3737
Mailing Address - Country:US
Mailing Address - Phone:307-472-3769
Mailing Address - Fax:307-472-3607
Practice Address - Street 1:915 S DAVID ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-3737
Practice Address - Country:US
Practice Address - Phone:307-472-3769
Practice Address - Fax:307-472-3607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY112255000Medicaid
WY1003982141OtherNPI
WY304479Medicare ID - Type Unspecified