Provider Demographics
NPI:1477534469
Name:WADE, MARVIN SCOTT (PA)
Entity Type:Individual
Prefix:MR
First Name:MARVIN
Middle Name:SCOTT
Last Name:WADE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9267 MEDICAL PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9139
Mailing Address - Country:US
Mailing Address - Phone:843-797-3636
Mailing Address - Fax:
Practice Address - Street 1:9267 MEDICAL PLAZA DR
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9139
Practice Address - Country:US
Practice Address - Phone:843-797-3636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1057840363A00000X
SC2091363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN