Provider Demographics
NPI:1699826149
Name:WADE, KENNETH ALAN (PA)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:ALAN
Last Name:WADE
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:1325 N 600 E
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-6738
Mailing Address - Country:US
Mailing Address - Phone:435-753-9999
Mailing Address - Fax:435-753-2301
Practice Address - Street 1:1325 N 600 E
Practice Address - Street 2:SUITE 102
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-6738
Practice Address - Country:US
Practice Address - Phone:435-753-9999
Practice Address - Fax:435-753-2301
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2016-11-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
UT1015921206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1015921206OtherSTATE LICENSE