Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207L00000X | Anesthesiologist | C00324 | AR |
NPI | 1013076801 |
---|---|
Provider Name | Ken Wade |
First Address | Little Rock, AR 72211-4316 |
Second Address | Little Rock, AR 72205-7202 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/12/2006 |
Last Update Date | 16/05/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
136873701 | (05) | AR |