1891838835 NPI number — DAVID C WADE PSY D

Table of content: DAVID C WADE PSY D (NPI 1891838835)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891838835 NPI number — DAVID C WADE PSY D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WADE
Provider First Name:
DAVID
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSY D
Provider Gender Code:
M

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:
1891838835
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/22/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 E MARINA WAY
Provider Second Line Business Mailing Address:
STE 221
Provider Business Mailing Address City Name:
HOOD RIVER
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97031-2353
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-493-1467
Provider Business Mailing Address Fax Number:
509-493-3765

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 E MARINA WAY
Provider Second Line Business Practice Location Address:
SUITE 221
Provider Business Practice Location Address City Name:
HOOD RIVER
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97031-2305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-436-2998
Provider Business Practice Location Address Fax Number:
541-436-2998
Provider Enumeration Date:
02/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  1081 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 400707 . This is a "VALUE OPTIONS" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 885235000 . This is a "REGENCE BCBSO" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: YC73001 . This is a "PACIFIC SOURCE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 115025 . This is a "MANAGED HEALTH NETWORK" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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