Provider Demographics
NPI:1548593916
Name:WM. WADE COLLISON MD
Entity Type:Organization
Organization Name:WM. WADE COLLISON MD
Other - Org Name:PRESCOTT PLASTIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:COLLISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-778-3838
Mailing Address - Street 1:1050 GAIL GARDNER WAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-1630
Mailing Address - Country:US
Mailing Address - Phone:928-778-3838
Mailing Address - Fax:928-778-5630
Practice Address - Street 1:1050 GAIL GARDNER WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-1630
Practice Address - Country:US
Practice Address - Phone:928-778-3838
Practice Address - Fax:928-778-5630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-16
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10644261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical