Provider Demographics
NPI:1053319004
Name:SKOGMAN, WADE DAVID (DC,CSCS,DAB)
Entity Type:Individual
Prefix:DR
First Name:WADE
Middle Name:DAVID
Last Name:SKOGMAN
Suffix:
Gender:M
Credentials:DC,CSCS,DAB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N8632 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:WI
Mailing Address - Zip Code:54165-8875
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:126 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:WI
Practice Address - Zip Code:54165-1475
Practice Address - Country:US
Practice Address - Phone:920-833-7844
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3140111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician