Basic Information
| Provider Information | |||||||||
| NPI: | 1558737817 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WADE | ||||||||
| FirstName: | STEPHANIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2215 NASHVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794101105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067255844 | ||||||||
| FaxNumber: | 8067236532 | ||||||||
| Practice Location | |||||||||
| Address1: | 7777 FOREST LN | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725667000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2015 | ||||||||
| LastUpdateDate: | 06/15/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA10026 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 31827764 | 05 | NM | MEDICAID | 8HN475 | 01 | TX | BCBS | OTHER | 1558737817 | 01 | TX | FIRSTCARE | OTHER | 626721YKT8 | 01 | TX | MEDICARE | OTHER | 356244903 | 05 | TX | MEDICAID |