Provider Demographics
NPI:1518969377
Name:WADE, MICHELLE PINTO (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:PINTO
Last Name:WADE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 SHADOW RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-0068
Mailing Address - Country:US
Mailing Address - Phone:215-219-8182
Mailing Address - Fax:
Practice Address - Street 1:10325 SAN JOSE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-6204
Practice Address - Country:US
Practice Address - Phone:904-717-1034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113264208000000X
PAMA0513422080A0000X
FLPA113264363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113755000Medicaid
PAMA051342OtherMEDICAL LICENSE
PAMA051342OtherMEDICAL LICENSE