MEDICARE: DR. WADE ALLAN JESPERSEN DPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	SC006516	PA
2	213ES0103X	Foot & Ankle Surgery Podiatrist	0843	AZ

General Provider Information

NPI Number	:	1174964654
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WADE ALLAN JESPERSEN DPM

Provider Business Mailing Address
First Line	:	14050 N 83RD AVE
Second Line	:	STE 290
City	:	PEORIA
State	:	AZ
Zip	:	85381-5650
Country	:	US
Telephone Number	:	888-495-4489
Fax Number	:	602-865-8090

Provider Business Practice Location Address
First Line	:	19350 E SILVER CREEK LN
Second Line	:
City	:	QUEEN CREEK
State	:	AZ
Zip	:	85142-9064
Country	:	US
Telephone Number	:	480-718-5400
Fax Number	:	877-666-4624

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2013
Last Update Date	:	05/09/2019

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