Provider Demographics
NPI:1598253577
Name:WADE, CHARLES E (NP)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:E
Last Name:WADE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2705 N LEBANON ST STE 305
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-8622
Mailing Address - Country:US
Mailing Address - Phone:765-485-8852
Mailing Address - Fax:
Practice Address - Street 1:2605 N LEBANON ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-1476
Practice Address - Country:US
Practice Address - Phone:765-485-8000
Practice Address - Fax:765-485-8239
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71007932A208M00000X, 363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN3000013406Medicaid
IN00001344950OtherANTHEM