Provider Demographics
NPI:1467625756
Name:VAN SICE, WADE CLARK (MD)
Entity type:Individual
Prefix:
First Name:WADE
Middle Name:CLARK
Last Name:VAN SICE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:530 9TH ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:OR
Practice Address - Zip Code:97439-7388
Practice Address - Country:US
Practice Address - Phone:541-997-7104
Practice Address - Fax:541-997-5975
Is Sole Proprietor?:No
Enumeration Date:2008-04-08
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN75050207X00000X
FL122314207X00000X
LAMD.202524207X00000X
ORMD222569207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1500356Medicaid