Provider Demographics
NPI:1760640171
Name:WOMMER, MARY FRANCIS (RT (R))
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:FRANCIS
Last Name:WOMMER
Suffix:
Gender:F
Credentials:RT (R)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 LAKE TRAVERSE DR
Mailing Address - Street 2:PO BOX 189
Mailing Address - City:SISSETON
Mailing Address - State:SD
Mailing Address - Zip Code:57262-7046
Mailing Address - Country:US
Mailing Address - Phone:605-742-3775
Mailing Address - Fax:605-698-3607
Practice Address - Street 1:100 LAKE TRAVERSE DR
Practice Address - Street 2:
Practice Address - City:SISSETON
Practice Address - State:SD
Practice Address - Zip Code:57262-7046
Practice Address - Country:US
Practice Address - Phone:605-742-3775
Practice Address - Fax:605-698-3607
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1062302471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography
Provider Identifiers
StateIdentifier IDID TypeIssuer
106230OtherAMERICAN REGISTRY OF RADIOLOGIC TECHNOLOGISTS (ARRT)
SD430085Medicaid