Basic Information
| Provider Information | |||||||||
| NPI: | 1982016788 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WONDERLICH | ||||||||
| FirstName: | THOMAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2003 KOOTENAI HEALTH WAY | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838146051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084765777 | ||||||||
| FaxNumber: | 2084765385 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | OROFINO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835449029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084765777 | ||||||||
| FaxNumber: | 2084765385 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2014 | ||||||||
| LastUpdateDate: | 11/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 9495056-1205 | UT | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | M13796 | ID | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.