Basic Information
| Provider Information | |||||||||
| NPI: | 1013987452 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WRAY | ||||||||
| FirstName: | ALAN | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2671 | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834032671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085234906 | ||||||||
| FaxNumber: | 2085232025 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 CHANNING WAY | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834047533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082272600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 08/08/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | M5030 | ID | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | M5030 | ID | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 000010165236 | 01 | REGENCE BLUE SHIELD OF IDAHO | OTHER | 002795600 | 05 | ID | MEDICAID | 8418154 | 05 | WA | MEDICAID | P00206340 | 01 | RAILROAD MEDICARE | OTHER | 000010150559 | 01 | ID | REGENCE BS OF IDAHO | OTHER | 1121800 | 01 | ID | MEDICARE PTAN | OTHER | 0192804 | 01 | WA | LABOR & INDUSTRIES | OTHER | 1121801 | 01 | ID | MEDICARE PTAN | OTHER | B4133 | 01 | ID | BLUE CROSS OF IDAHO | OTHER |