Basic Information
Provider Information | |||||||||
NPI: | 1184613929 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WERNECKE | ||||||||
FirstName: | WADE | ||||||||
MiddleName: | CARL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 300 WERNER ST | ||||||||
Address2: |   | ||||||||
City: | HOT SPRINGS | ||||||||
State: | AR | ||||||||
PostalCode: | 719136406 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5016221043 | ||||||||
FaxNumber: | 5016221199 | ||||||||
Practice Location | |||||||||
Address1: | 300 WERNER ST | ||||||||
Address2: |   | ||||||||
City: | HOT SPRINGS | ||||||||
State: | AR | ||||||||
PostalCode: | 719136406 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5016221043 | ||||||||
FaxNumber: | 5016221199 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/14/2005 | ||||||||
LastUpdateDate: | 02/07/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 31819 | MN | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
ID | Type | State | Issuer | Description | 2M151WE | 01 | MN | BCBS | OTHER | 053502800 | 05 | MN |   | MEDICAID | HP31594 | 01 | MN | HEALTHPARTNERS | OTHER | 5H0526972 | 01 | AR | MEDICARELINKED | OTHER |