Provider Demographics
NPI:1992817241
Name:WENNEN, WILLIAM W (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:W
Last Name:WENNEN
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 1:1275 SADLER WAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-3171
Mailing Address - Country:US
Mailing Address - Phone:907-451-8775
Mailing Address - Fax:907-451-7716
Practice Address - Street 1:1275 SADLER WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-3171
Practice Address - Country:US
Practice Address - Phone:907-451-8775
Practice Address - Fax:907-451-7716
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA1264174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD1264Medicaid
AKK0000WFBBVMedicare ID - Type Unspecified
AKC97275Medicare UPIN