Provider Demographics
NPI:1689172413
Name:WADE, DARYL GENE II (PTA)
Entity Type:Individual
Prefix:
First Name:DARYL
Middle Name:GENE
Last Name:WADE
Suffix:II
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 SIKES AVE
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-5021
Mailing Address - Country:US
Mailing Address - Phone:573-471-5755
Mailing Address - Fax:573-471-5884
Practice Address - Street 1:1102 SIKES AVE
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-5021
Practice Address - Country:US
Practice Address - Phone:573-471-5755
Practice Address - Fax:573-471-5884
Is Sole Proprietor?:No
Enumeration Date:2018-01-26
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008024826225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant