Provider Demographics
NPI:1770641201
Name:MORCOM, WADE DOUGLAS (CRNA)
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:DOUGLAS
Last Name:MORCOM
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:WHISPERING PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28327-9368
Mailing Address - Country:US
Mailing Address - Phone:910-322-3460
Mailing Address - Fax:
Practice Address - Street 1:2817 REILLY ROAD
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310
Practice Address - Country:US
Practice Address - Phone:910-907-8879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX654610367500000X
VA0024166305367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVAA101287Medicare PIN