Provider Demographics
NPI:1922145101
Name:WADE, TY C (DC)
Entity Type:Individual
Prefix:MR
First Name:TY
Middle Name:C
Last Name:WADE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 E. GREEN BAY AVE.
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SAUKVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53080
Mailing Address - Country:US
Mailing Address - Phone:262-284-0022
Mailing Address - Fax:262-268-0715
Practice Address - Street 1:620 E. GREEN BAY AVE.
Practice Address - Street 2:SUITE 104
Practice Address - City:SAUKVILLE
Practice Address - State:WI
Practice Address - Zip Code:53080
Practice Address - Country:US
Practice Address - Phone:262-284-0022
Practice Address - Fax:262-268-0715
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4012-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38950300Medicaid
WI202500022OtherUHC
WI649385OtherACN
WI202500022OtherWEA
WI202500022OtherWPPN
WI389-50300Medicaid
WI202500022OtherWEA
WI38950300Medicaid