Provider Demographics
NPI:1497714406
Name:WADE, NICOLE L (DO)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:L
Last Name:WADE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:L
Other - Last Name:BATEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:100 KEOKEA PL
Mailing Address - Street 2:
Mailing Address - City:KULA
Mailing Address - State:HI
Mailing Address - Zip Code:96790-7450
Mailing Address - Country:US
Mailing Address - Phone:808-876-4331
Mailing Address - Fax:808-876-4332
Practice Address - Street 1:100 KEOKEA PL
Practice Address - Street 2:
Practice Address - City:KULA
Practice Address - State:HI
Practice Address - Zip Code:96790-7450
Practice Address - Country:US
Practice Address - Phone:808-876-4331
Practice Address - Fax:808-876-4332
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-010324207Q00000X
WI48398207Q00000X
HIDOS-1975207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43530000Medicaid
OH0058772Medicaid