Provider Demographics
NPI:1386633220
Name:WANDERER, ALAN A (MD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:A
Last Name:WANDERER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2055 N 22ND AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-2783
Mailing Address - Country:US
Mailing Address - Phone:406-582-1111
Mailing Address - Fax:406-582-1112
Practice Address - Street 1:2055 N 22ND AVE
Practice Address - Street 2:STE 1
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-2783
Practice Address - Country:US
Practice Address - Phone:406-582-1111
Practice Address - Fax:406-582-1112
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MT8795207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0143752Medicaid
MT0143752Medicaid