Basic Information
| Provider Information | |||||||||
| NPI: | 1366418493 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WADE | ||||||||
| FirstName: | ZANE | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 491270 | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063892425 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1230 BAXTER ST | ||||||||
| Address2: | PATHOLOGY DEPT | ||||||||
| City: | ATHENS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063892425 | ||||||||
| FaxNumber: | 7063892426 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 08/13/2010 | ||||||||
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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 | 207ZP0102X | 052236 | GA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 529084968A | 05 | GA | MEDICAID | BW8141296 | 01 | GA | DEA | OTHER | P00194114 | 01 | GA | RAILROAD MEDICARE | OTHER |