Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 111046 | AK |
NPI | 1003278698 |
---|---|
Provider Name | Dr. Thomas Nelson Wanat III |
First Address | Anchorage, AK 99508-5919 |
Second Address | Anchorage, AK 99508-5919 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/03/2016 |
Last Update Date | 27/07/2016 |