Provider Demographics
NPI:1801854500
Name:ETHEREDGE, WADE (MD)
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:
Last Name:ETHEREDGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5607 LANDS END ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78734-1515
Mailing Address - Country:US
Mailing Address - Phone:512-266-2480
Mailing Address - Fax:
Practice Address - Street 1:2400 ROUND ROCK AVE
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-4004
Practice Address - Country:US
Practice Address - Phone:512-341-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1992207PE0004X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX104414104Medicaid
TX8A1516Medicare ID - Type Unspecified
TX104414104Medicaid