Provider Demographics
NPI:1033173786
Name:BABCOCK, WADE (PAC)
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:
Last Name:BABCOCK
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 K 96 HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530
Mailing Address - Country:US
Mailing Address - Phone:620-792-4383
Mailing Address - Fax:620-792-2058
Practice Address - Street 1:1514 K 96 HIGHWAY
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530
Practice Address - Country:US
Practice Address - Phone:620-792-4383
Practice Address - Fax:620-792-2058
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1500615363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00112736OtherRR MC
11913OtherPREFERRED HEALTH
11913OtherPREFERRED HEALTH
P00112736OtherRR MC