Basic Information
| Provider Information | |||||||||
| NPI: | 1992926893 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WADE | ||||||||
| FirstName: | LYDIA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 CENTRA CARE CIRCLE | ||||||||
| Address2: | CENTRA CARE CLINIC - WOMEN'S & CHILDRENS | ||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563035000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206543610 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1900 CENTRA CARE CIRCLE | ||||||||
| Address2: | CENTRA CARE CLINIC - WOMEN'S & CHILDRENS | ||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563035000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206543610 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 11/11/2009 | ||||||||
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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 | 207V00000X | 52114 | MN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 4301086305 | MI | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.