Basic Information
| Provider Information | |||||||||
| NPI: | 1710959168 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOMENGEN | ||||||||
| FirstName: | WADE | ||||||||
| MiddleName: | TRAVIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 N C AVE | ||||||||
| Address2: | |||||||||
| City: | THERMOPOLIS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 824432410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078645534 | ||||||||
| FaxNumber: | 3078649470 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 N C AVE | ||||||||
| Address2: | |||||||||
| City: | THERMOPOLIS | ||||||||
| State: | WY | ||||||||
| PostalCode: | 824432410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078645534 | ||||||||
| FaxNumber: | 3078649470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 06/07/2012 | ||||||||
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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 | 207Q00000X | 5946AWY | WY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | BB5442001 | 01 | WA | DEA | OTHER | 5946AWY | 01 | WY | WY MEDICAL LICENSE # | OTHER | 113009900 | 05 | WY | MEDICAID | 613WB97 | 01 | WY | WY CONTROLLED SUBSTANCE # | OTHER |