Provider Demographics
NPI:1649211566
Name:GORSUCH, WANDA LEA (MD)
Entity Type:Individual
Prefix:DR
First Name:WANDA
Middle Name:LEA
Last Name:GORSUCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 25TH ST S
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-5183
Mailing Address - Country:US
Mailing Address - Phone:406-731-8888
Mailing Address - Fax:406-731-8318
Practice Address - Street 1:1401 25TH ST S
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-5183
Practice Address - Country:US
Practice Address - Phone:406-731-8888
Practice Address - Fax:406-731-8318
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT6360207XS0106X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT184609700OtherFEDERAL WORK COMP
810347861OtherCHAMPUS
MT0080132Medicaid
MT810347861004OtherEBMS
MT000097000OtherBLUE CROSS BLUE SHIELD
MT200023483OtherRAILROAD MEDICARE
MT0139917OtherWASHINGTON L & I
MT0139917OtherWASHINGTON L & I
810347861OtherCHAMPUS
MT0232060001Medicare NSC