Provider Demographics
NPI:1568862001
Name:WADE, AMBER JUNE (PA-C)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:JUNE
Last Name:WADE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:JUNE
Other - Last Name:WILLOUGHBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7714 POPLAR AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-3941
Mailing Address - Country:US
Mailing Address - Phone:901-683-0055
Mailing Address - Fax:901-922-6722
Practice Address - Street 1:7945 WOLF RIVER BLVD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1762
Practice Address - Country:US
Practice Address - Phone:901-683-0055
Practice Address - Fax:901-685-2969
Is Sole Proprietor?:No
Enumeration Date:2014-09-03
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2585363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ010840Medicaid
TNQ010840Medicaid