Provider Demographics
NPI:1356307458
Name:WADE, MARK ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
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 1:2310 PEGER RD
Mailing Address - Street 2:STE 105
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-5315
Mailing Address - Country:US
Mailing Address - Phone:907-479-2663
Mailing Address - Fax:907-479-2691
Practice Address - Street 1:2310 PEGER RD
Practice Address - Street 2:STE 105
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-5315
Practice Address - Country:US
Practice Address - Phone:907-479-2663
Practice Address - Fax:907-479-2691
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4018207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD07391Medicaid
AK194028200OtherDEPT OF LABOR ID
AKMD07392Medicaid
AKMD6149Medicaid
AK194028200OtherDEPT OF LABOR ID
AKK151887Medicare ID - Type UnspecifiedMEDICARE ID
AKMD07392Medicaid