Provider Demographics
NPI:1578227294
Name:WADE, ANTWAIN
Entity Type:Individual
Prefix:
First Name:ANTWAIN
Middle Name:
Last Name:WADE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N STATE HIGHWAY 360 APT 1026
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-3588
Mailing Address - Country:US
Mailing Address - Phone:317-413-5205
Mailing Address - Fax:
Practice Address - Street 1:400 N STATE HIGHWAY 360 APT 1026
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-3588
Practice Address - Country:US
Practice Address - Phone:317-413-5205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN83-1958589Medicaid