Provider Demographics
NPI:1659357176
Name:MARION, WADE H (PAC)
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:H
Last Name:MARION
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MEDICAL CENTER BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157
Mailing Address - Country:US
Mailing Address - Phone:336-716-6192
Mailing Address - Fax:336-716-4318
Practice Address - Street 1:MEDICAL CENTER BOULEVARD
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157
Practice Address - Country:US
Practice Address - Phone:336-716-6192
Practice Address - Fax:336-716-4318
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101159363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2469136OtherUNITED HEALTHCARE
NC1659357176OtherVIRGINIA MEDICAID
NCD5133OtherMEDCOST
NC1659357176OtherTRICARE
NC1659357176Medicaid
NC1659357176OtherPARTNERS
7010743OtherAETNA
NC1608PAOtherSC MEDICAID
NC1659357176Medicaid
NC1608PAOtherSC MEDICAID
NCNCB633AMedicare PIN