Provider Demographics
NPI:1497949697
Name:WILLIAM W WENNEN MD FACS
Entity Type:Organization
Organization Name:WILLIAM W WENNEN MD FACS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:W
Authorized Official - Last Name:WENNEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-451-8775
Mailing Address - Street 1:575 RIVERSTONE WAY
Mailing Address - Street 2:UNIT 1
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-2939
Mailing Address - Country:US
Mailing Address - Phone:907-451-8775
Mailing Address - Fax:907-451-7716
Practice Address - Street 1:575 RIVERSTONE WAY
Practice Address - Street 2:UNIT 1
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-2939
Practice Address - Country:US
Practice Address - Phone:907-451-8775
Practice Address - Fax:907-451-7716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-30
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA1264208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKC97275Medicare UPIN