Provider Demographics
NPI:1225227762
Name:RODENMAYER, WADE (PA)
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:
Last Name:RODENMAYER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-5502
Mailing Address - Country:US
Mailing Address - Phone:518-584-1656
Mailing Address - Fax:518-584-1822
Practice Address - Street 1:409 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-5502
Practice Address - Country:US
Practice Address - Phone:518-584-1656
Practice Address - Fax:518-584-1822
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012187363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00621563OtherRR MEDICARE
NYPA2237Medicare PIN