Provider Demographics
NPI:1336262351
Name:WADE, TOMMY DEAN (PT)
Entity Type:Individual
Prefix:
First Name:TOMMY
Middle Name:DEAN
Last Name:WADE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4115 MICHAEL RD.
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:75025
Mailing Address - Country:US
Mailing Address - Phone:405-348-8515
Mailing Address - Fax:
Practice Address - Street 1:6400 N SANTA FE AVE
Practice Address - Street 2:STE. B
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-9126
Practice Address - Country:US
Practice Address - Phone:405-840-2903
Practice Address - Fax:405-840-3256
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1446225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist