Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081P2900X | Pain Medicine | 242667 | NY |
NPI | 1114067261 |
---|---|
Provider Name | Dr. Stephen Wade |
First Address | Utica, NY 13502-5178 |
Second Address | Utica, NY 13502-5178 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/02/2007 |
Last Update Date | 22/05/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
03168343 | MEDICAID (01) | NY |
RB3864 | MEDICARE PTAN (01) |