Basic Information
| Provider Information | |||||||||
| NPI: | 1699867812 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GASTON | ||||||||
| FirstName: | WADE | ||||||||
| MiddleName: | HAMPTON | ||||||||
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| NameSuffix: | IV | ||||||||
| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2416 HIGHWAY 45 N | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 397051320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623276705 | ||||||||
| FaxNumber: | 6623276760 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 HIGHWAY 49 S | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | RICHLAND | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392189425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7692338844 | ||||||||
| FaxNumber: | 7692511825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 11/09/2016 | ||||||||
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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 | 225100000X | PT2964 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.