Provider Demographics
NPI:1053107672
Name:MOORE, WADE KYLE
Entity type:Individual
Prefix:
First Name:WADE
Middle Name:KYLE
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 MONARCH LN
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:KS
Mailing Address - Zip Code:67502-9115
Mailing Address - Country:US
Mailing Address - Phone:620-245-4715
Mailing Address - Fax:
Practice Address - Street 1:1701 E 23RD AVE
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67502-9907
Practice Address - Country:US
Practice Address - Phone:620-524-0799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-18
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KS43-558280-122367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program