Basic Information
| Provider Information | |||||||||
| NPI: | 1174964654 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JESPERSEN | ||||||||
| FirstName: | WADE | ||||||||
| MiddleName: | ALLAN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14050 N 83RD AVE | ||||||||
| Address2: | STE 290 | ||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853815650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8884954489 | ||||||||
| FaxNumber: | 6028658090 | ||||||||
| Practice Location | |||||||||
| Address1: | 19350 E SILVER CREEK LN | ||||||||
| Address2: | |||||||||
| City: | QUEEN CREEK | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851429064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807185400 | ||||||||
| FaxNumber: | 8776664624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2013 | ||||||||
| LastUpdateDate: | 05/09/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | SC006516 | PA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | 0843 | AZ | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.