Provider Demographics
NPI:1679510101
Name:WICKSTROM, GLENDA (MD)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:
Last Name:WICKSTROM
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 1:315 N 25TH ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59101-1314
Mailing Address - Country:US
Mailing Address - Phone:406-237-4050
Mailing Address - Fax:406-237-4004
Practice Address - Street 1:315 N 25TH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-1328
Practice Address - Country:US
Practice Address - Phone:406-237-4050
Practice Address - Fax:406-237-4004
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10054207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine