Provider Demographics
NPI:1093224768
Name:WADE, MOLLY CLAIRE (PA)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:CLAIRE
Last Name:WADE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:C
Other - Last Name:MEES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4600 MEMORIAL DR STE 120
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5359
Mailing Address - Country:US
Mailing Address - Phone:618-222-1020
Mailing Address - Fax:
Practice Address - Street 1:4600 MEMORIAL DR STE 120
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226
Practice Address - Country:US
Practice Address - Phone:618-222-1020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006338363AS0400X
085006338363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical