Provider Demographics
NPI:1477107415
Name:WADE, SEAN MICHAEL
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:MICHAEL
Last Name:WADE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 N ALFORD ST
Mailing Address - Street 2:
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-8309
Mailing Address - Country:US
Mailing Address - Phone:760-608-6672
Mailing Address - Fax:
Practice Address - Street 1:1400 N NORMA ST STE 133
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-2577
Practice Address - Country:US
Practice Address - Phone:760-499-7406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-29
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator