Provider Demographics
NPI:1306832571
Name:WADE, GARY L (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:WADE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:484 SNIDER DR
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-8075
Mailing Address - Country:US
Mailing Address - Phone:530-340-1428
Mailing Address - Fax:
Practice Address - Street 1:2422 20TH ST SW
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-6201
Practice Address - Country:US
Practice Address - Phone:701-952-4854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000223302085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA49522Medicare UPIN