Provider Demographics
NPI:1801834791
Name:NILSON, WADE A (PA)
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:A
Last Name:NILSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 AUGUSTA DR
Mailing Address - Street 2:
Mailing Address - City:VERMILLION
Mailing Address - State:SD
Mailing Address - Zip Code:57069-3462
Mailing Address - Country:US
Mailing Address - Phone:605-624-3729
Mailing Address - Fax:605-677-6569
Practice Address - Street 1:801 5TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51101-1394
Practice Address - Country:US
Practice Address - Phone:712-279-2010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001536363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
14217OtherWELLMARK BCBS
SD6824154Medicaid
25602OtherMIDLANDS CHOICE
14217OtherWELLMARK BCBS
I12841Medicare PIN