Provider Demographics
NPI:1497155279
Name:WADE, KATHRYN ANNE (PA)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ANNE
Last Name:WADE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:ANNE
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:2145 HENRY TECKLENBURG DR
Practice Address - Street 2:SUITE 220
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5893
Practice Address - Country:US
Practice Address - Phone:843-723-8823
Practice Address - Fax:843-766-6551
Is Sole Proprietor?:No
Enumeration Date:2014-08-28
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2170363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1982PAMedicaid