Provider Demographics
NPI:1558400713
Name:WADE, GEORGIANNA (LMT)
Entity Type:Individual
Prefix:MRS
First Name:GEORGIANNA
Middle Name:
Last Name:WADE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 W POWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-7050
Mailing Address - Country:US
Mailing Address - Phone:503-666-9171
Mailing Address - Fax:503-667-9072
Practice Address - Street 1:343 W POWELL BLVD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7050
Practice Address - Country:US
Practice Address - Phone:503-666-9171
Practice Address - Fax:503-667-9072
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7812174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist