Basic Information
| Provider Information | |||||||||
| NPI: | 1972748879 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | WADE | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8800 SE SUNNYSIDE RD. | ||||||||
| Address2: | STE. 300-N | ||||||||
| City: | CLACKAMAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970155738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036595115 | ||||||||
| FaxNumber: | 2083770313 | ||||||||
| Practice Location | |||||||||
| Address1: | 341 THREE RIVERS DR. | ||||||||
| Address2: | |||||||||
| City: | KELSO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986263100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602005079 | ||||||||
| FaxNumber: | 2083770313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2008 | ||||||||
| LastUpdateDate: | 04/06/2012 | ||||||||
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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 | 237700000X | HA-1667 | ID | N | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist | 237700000X | HA60263662 | WA | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
No ID Information.