Provider Demographics
NPI:1194800334
Name:ANDERSON, WILLIAM WALLACE (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:WALLACE
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1400 BARBARA LOOP SE STE A
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1088
Mailing Address - Country:US
Mailing Address - Phone:505-892-9711
Mailing Address - Fax:505-892-5206
Practice Address - Street 1:1400 BARBARA LOOP SE STE A
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1088
Practice Address - Country:US
Practice Address - Phone:505-892-9711
Practice Address - Fax:505-892-5206
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM78-105207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM85-0455201OtherFEDID
NM850455201OtherDEFAULT NUMBER
NM17418Medicaid
NM17418Medicaid