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General NPI Number Information
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NPI Number | 1710959168
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Entity Type | Individual
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Provider Name | WADE TRAVIS BOMENGEN M.D.
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Gender | Male
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Dates
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Enumeration Date | 02/01/2006
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 120 N C AVE
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City | THERMOPOLIS
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State | WY
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Zip | 82443-2410
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Country | US
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Telephone | 307-864-5534
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Fax | 307-864-9470
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Provider Business Mailing Address
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Address Line | 120 N C AVE
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City | THERMOPOLIS
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State | WY
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Zip | 82443-2410
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Country | US
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Telephone | 307-864-5534
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Fax | 307-864-9470
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 5946AWY
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License Number State | WY
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