Provider Demographics
NPI:1255408654
Name:PINCOMB, GWENDOLYN ALICE (MD)
Entity type:Individual
Prefix:MS
First Name:GWENDOLYN
Middle Name:ALICE
Last Name:PINCOMB
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 1:2525 E BROADWAY ST
Mailing Address - Street 2:SUITE 202A
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-8049
Mailing Address - Country:US
Mailing Address - Phone:406-457-4280
Mailing Address - Fax:406-457-4278
Practice Address - Street 1:2525 E BROADWAY ST
Practice Address - Street 2:SUITE 202A
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-8049
Practice Address - Country:US
Practice Address - Phone:406-457-4280
Practice Address - Fax:406-457-4278
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10181174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0073355Medicaid
MT0073355Medicaid