Provider Demographics
NPI:1063497758
Name:WADE, THERESA BERGEN (APRN)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:BERGEN
Last Name:WADE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MS
Other - First Name:THERESA
Other - Middle Name:ANNETTE
Other - Last Name:WADE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN
Mailing Address - Street 1:83-5737 KANELE ST
Mailing Address - Street 2:
Mailing Address - City:CAPTAIN COOK
Mailing Address - State:HI
Mailing Address - Zip Code:96704-8329
Mailing Address - Country:US
Mailing Address - Phone:808-333-5977
Mailing Address - Fax:
Practice Address - Street 1:83-5737 KANELE ST
Practice Address - Street 2:
Practice Address - City:CAPTAIN COOK
Practice Address - State:HI
Practice Address - Zip Code:96704
Practice Address - Country:US
Practice Address - Phone:808-333-5977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7512363LP0808X, 363L00000X, 363LF0000X
HIAPRN - 1950363LP0808X, 363LF0000X
CA509869363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily