Provider Demographics
NPI:1235695149
Name:WADE, SCOTT WILLIAM (LPN)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:WILLIAM
Last Name:WADE
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 CIRCUIT RD
Mailing Address - Street 2:
Mailing Address - City:BELLPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11713-2903
Mailing Address - Country:US
Mailing Address - Phone:914-258-7851
Mailing Address - Fax:
Practice Address - Street 1:29 CIRCUIT RD
Practice Address - Street 2:
Practice Address - City:BELLPORT
Practice Address - State:NY
Practice Address - Zip Code:11713-2903
Practice Address - Country:US
Practice Address - Phone:914-258-7851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-15
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY331303164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse