Provider Demographics
NPI:1386626463
Name:CHRISTENSEN, WADE K (PA)
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:K
Last Name:CHRISTENSEN
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 1:1880 JOHN ADAMS PKWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4315
Mailing Address - Country:US
Mailing Address - Phone:208-524-6633
Mailing Address - Fax:208-524-9952
Practice Address - Street 1:1880 JOHN ADAMS PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4315
Practice Address - Country:US
Practice Address - Phone:208-524-6633
Practice Address - Fax:208-524-9952
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA268363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPALR9OtherBLUE CROSS PROVIDER NUMBE
ID000010017817OtherBLUE SHIELD INDIVIUAL
ID807937700Medicaid
ID000010027582OtherREGENCE BLUESHIELD GROUP
ID807659300Medicaid
ID1134140148OtherBAKER FAMILY PRACT NPI
ID8K123OtherBLUE CROSS GROUP
IDDE1614OtherRAILROAD MCR GROUP
ID805622400Medicaid
IDP00275624OtherRAILROAD MEDICARE
IDDE1614OtherRAILROAD MCR GROUP
ID1666155Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
ID805622400Medicaid