Provider Demographics
NPI:1205281052
Name:WADE, MICHAEL ANDREW I
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANDREW
Last Name:WADE
Suffix:I
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:USS PAUL HAMILTON
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:96667-1278
Mailing Address - Country:US
Mailing Address - Phone:619-556-9229
Mailing Address - Fax:
Practice Address - Street 1:USS PAUL HAMILTON
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:96667-1278
Practice Address - Country:US
Practice Address - Phone:619-556-9229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-29
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman