Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207XX0005X | Sports Medicine Orthopaedic Surgeon | M3813 | ID |
NPI | 1063418903 |
---|---|
Provider Name | Dr. George A. Wade |
First Address | Boise, ID 83706-3009 |
Second Address | Boise, ID 83706-3009 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/06/2005 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000010005427 | REGENCE BLUE SHIELD # (01) | ID |
38133 | BLUE CROSS OF IDAHO # (01) | ID |
C36862 | (02) | ID |