Provider Demographics
NPI:1831233790
Name:WUNDROW, LARRY W (MS, AUDIOLOGIST)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:W
Last Name:WUNDROW
Suffix:
Gender:M
Credentials:MS, AUDIOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-2611
Mailing Address - Country:US
Mailing Address - Phone:406-549-1951
Mailing Address - Fax:406-542-5682
Practice Address - Street 1:601 S ORANGE ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-2611
Practice Address - Country:US
Practice Address - Phone:406-549-1951
Practice Address - Fax:406-542-5682
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT178231H00000X
MT114237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0569257Medicaid
MT029108OtherBCBBSMT
MT0531076Medicaid
MT1831233790Medicaid
MT011003599Medicare PIN
MT0531076Medicaid