Provider Demographics
NPI:1902393614
Name:WADE, WILLIAM K (BOCP, COF, CPED)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:K
Last Name:WADE
Suffix:
Gender:M
Credentials:BOCP, COF, CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3004 BIENVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-4370
Mailing Address - Country:US
Mailing Address - Phone:228-875-3828
Mailing Address - Fax:228-436-3580
Practice Address - Street 1:3004 BIENVILLE BLVD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-4370
Practice Address - Country:US
Practice Address - Phone:228-875-3828
Practice Address - Fax:228-436-3580
Is Sole Proprietor?:No
Enumeration Date:2018-04-18
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC50109222Z00000X, 224L00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist