Provider Demographics
NPI:1063658706
Name:WADE, DANA M (PT)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:M
Last Name:WADE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 VISTA RIO BONITO DR
Mailing Address - Street 2:
Mailing Address - City:ALTO
Mailing Address - State:NM
Mailing Address - Zip Code:88312-9400
Mailing Address - Country:US
Mailing Address - Phone:575-808-8721
Mailing Address - Fax:575-808-8723
Practice Address - Street 1:1129 MECHEM DR STE C
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-7292
Practice Address - Country:US
Practice Address - Phone:575-808-8721
Practice Address - Fax:575-808-8723
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-31
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3987225100000X
TX1087419225100000X
NMPT3987225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM12757349Medicaid