1205909793 NPI number — GARY L WADE MD

Table of content: (NPI 1205909793)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205909793 NPI number — GARY L WADE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GARY L WADE MD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205909793
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1086
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YREKA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
96097-1086
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-842-7297
Provider Business Mailing Address Fax Number:
530-842-9054

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
444 BRUCE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YREKA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96097-3450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-842-7297
Provider Business Practice Location Address Fax Number:
530-842-9054
Provider Enumeration Date:
11/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WADE
Authorized Official First Name:
GARY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
530-842-7297

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GR0041660 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com