Healthcare Provider Details

I. General information

NPI: 1801827027
Provider Name (Legal Business Name): BRYAN GLENN WACHTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4315 DIPLOMACY DR ATTN: SHERRY REEDY
ANCHORAGE AK
99508-5926
US

IV. Provider business mailing address

4315 DIPLOMACY DR ATTN: SHERRY REEDY
ANCHORAGE AK
99508-5926
US

V. Phone/Fax

Practice location:
  • Phone: 907-729-3971
  • Fax: 907-729-1542
Mailing address:
  • Phone: 907-729-3971
  • Fax: 907-729-1542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number4918
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: