Provider Demographics
NPI:1750684411
Name:GREEN, WADE (MED, ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:WADE
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:MED, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 HICKORY
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79698
Mailing Address - Country:US
Mailing Address - Phone:325-670-5840
Mailing Address - Fax:
Practice Address - Street 1:2200 HICKORY
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79698
Practice Address - Country:US
Practice Address - Phone:325-670-1188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-17
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT40132255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer