Provider Demographics
NPI:1982223087
Name:GILLARD, WADE (FNP-C)
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:
Last Name:GILLARD
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 NELSON RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-4187
Mailing Address - Country:US
Mailing Address - Phone:337-310-2273
Mailing Address - Fax:337-310-4520
Practice Address - Street 1:4201 NELSON RD STE 100
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4187
Practice Address - Country:US
Practice Address - Phone:337-310-2273
Practice Address - Fax:337-310-4520
Is Sole Proprietor?:No
Enumeration Date:2020-04-09
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA212171363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2573063Medicaid