Provider Demographics
NPI:1689146128
Name:WADE, JONATHAN (APRN-CRNA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:WADE
Suffix:
Gender:M
Credentials:APRN-CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9005 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-9489
Mailing Address - Country:US
Mailing Address - Phone:208-351-5470
Mailing Address - Fax:
Practice Address - Street 1:601 W LEOTA ST
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-6525
Practice Address - Country:US
Practice Address - Phone:308-568-8470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-21
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE101511367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered