Provider Demographics
NPI:1639428667
Name:KERNAN, WADE ROBERT (IDC)
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:ROBERT
Last Name:KERNAN
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USS ABRAHAM LINCOLN
Mailing Address - Street 2:CVN 72
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96612-2872
Mailing Address - Country:US
Mailing Address - Phone:757-444-5199
Mailing Address - Fax:
Practice Address - Street 1:USS ABRAHAM LINCOLN
Practice Address - Street 2:CVN 72
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96612-2872
Practice Address - Country:US
Practice Address - Phone:757-444-5199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-06
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman