Basic Information
| Provider Information | |||||||||
| NPI: | 1467625756 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANSICE | ||||||||
| FirstName: | WADE | ||||||||
| MiddleName: | CLARK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2055 MILITARY TRL | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | JUPITER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334587801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617449733 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2055 MILITARY TRL STE 204 | ||||||||
| Address2: | |||||||||
| City: | JUPITER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334587830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617449733 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2008 | ||||||||
| LastUpdateDate: | 09/19/2018 | ||||||||
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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 | 207X00000X | 122314 | FL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1500356 | 05 | LA | MEDICAID |