Healthcare Provider Details

I. General information

NPI: 1497949697
Provider Name (Legal Business Name): WILLIAM W WENNEN MD FACS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 08/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 RIVERSTONE WAY UNIT 1
FAIRBANKS AK
99709-2939
US

IV. Provider business mailing address

575 RIVERSTONE WAY UNIT 1
FAIRBANKS AK
99709-2939
US

V. Phone/Fax

Practice location:
  • Phone: 907-451-8775
  • Fax: 907-451-7716
Mailing address:
  • Phone: 907-451-8775
  • Fax: 907-451-7716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberAA1264
License Number StateAK

VIII. Authorized Official

Name: DR. WILLIAM W WENNEN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 907-451-8775