Provider Demographics
NPI:1073236097
Name:WADLOW, HUNTER ELIJAH
Entity Type:Individual
Prefix:
First Name:HUNTER
Middle Name:ELIJAH
Last Name:WADLOW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7245 RAIDER RD STE C
Mailing Address - Street 2:
Mailing Address - City:BONNE TERRE
Mailing Address - State:MO
Mailing Address - Zip Code:63628-3767
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7245 RAIDER RD STE C
Practice Address - Street 2:
Practice Address - City:BONNE TERRE
Practice Address - State:MO
Practice Address - Zip Code:63628-3767
Practice Address - Country:US
Practice Address - Phone:573-358-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-23
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022037256363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner