Basic Information
| Provider Information | |||||||||
| NPI: | 1952371221 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WADE | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 RAMPART WAY | ||||||||
| Address2: | 300B | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802306440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033274700 | ||||||||
| FaxNumber: | 3033274711 | ||||||||
| Practice Location | |||||||||
| Address1: | 1411 S POTOMAC ST | ||||||||
| Address2: | STE 360 | ||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800124536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033274700 | ||||||||
| FaxNumber: | 3033274711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 363LA2200X | 129293 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 59153563 | 05 | CO | MEDICAID |