Healthcare Provider Details

I. General information

NPI: 1386633220
Provider Name (Legal Business Name): ALAN A WANDERER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 N 22ND AVE STE 1
BOZEMAN MT
59718-2783
US

IV. Provider business mailing address

2055 N 22ND AVE STE 1
BOZEMAN MT
59718-2783
US

V. Phone/Fax

Practice location:
  • Phone: 406-582-1111
  • Fax: 406-582-1112
Mailing address:
  • Phone: 406-582-1111
  • Fax: 406-582-1112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number8795
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: