Provider Demographics
NPI:1063458586
Name:WADE, TRACY C (ARNP)
Entity Type:Individual
Prefix:MISS
First Name:TRACY
Middle Name:C
Last Name:WADE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 PIEDMONT CUTOFF
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35903-2708
Mailing Address - Country:US
Mailing Address - Phone:256-492-0131
Mailing Address - Fax:256-494-6000
Practice Address - Street 1:242 BROCKFORD RD
Practice Address - Street 2:
Practice Address - City:HEFLIN
Practice Address - State:AL
Practice Address - Zip Code:36264-1608
Practice Address - Country:US
Practice Address - Phone:256-463-2021
Practice Address - Fax:256-463-2024
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-074382NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL891010520Medicaid
AL108870Medicaid
AL510I500463Medicare PIN
AL891010520Medicaid
AL108870Medicaid