Provider Demographics
NPI:1568425924
Name:WADE, CHRIS (PA-C)
Entity Type:Individual
Prefix:
First Name:CHRIS
Middle Name:
Last Name:WADE
Suffix:
Gender:M
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 1:370 E COURTLAND ST
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-9054
Mailing Address - Country:US
Mailing Address - Phone:309-291-0899
Mailing Address - Fax:309-291-0927
Practice Address - Street 1:370 E COURTLAND ST
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:IL
Practice Address - Zip Code:61550-9054
Practice Address - Country:US
Practice Address - Phone:309-291-0899
Practice Address - Fax:309-291-0927
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001605363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00386420OtherRAILROAD MEDICARE
ILP00386420OtherRAILROAD MEDICARE
ILQ27146Medicare UPIN