Provider Demographics
NPI:1396124897
Name:KIMBERLY J WONDERLICH MD FAAD DERMATOLOGY LLC
Entity type:Organization
Organization Name:KIMBERLY J WONDERLICH MD FAAD DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:WONDERLICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-456-1979
Mailing Address - Street 1:2775 COLLEGE RD
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-3751
Mailing Address - Country:US
Mailing Address - Phone:907-456-1979
Mailing Address - Fax:907-456-1903
Practice Address - Street 1:2775 COLLEGE ROAD
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709
Practice Address - Country:US
Practice Address - Phone:907-456-1979
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-29
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK8102207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty