Healthcare Provider Details

I. General information

NPI: 1801243902
Provider Name (Legal Business Name): LAURA KATHERINE WADE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2016
Last Update Date: 01/11/2024
Certification Date: 01/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W UNIVERSITY AVE STE 112
FLAGSTAFF AZ
86001-3154
US

IV. Provider business mailing address

1600 W UNIVERSITY AVE STE 112
FLAGSTAFF AZ
86001-3154
US

V. Phone/Fax

Practice location:
  • Phone: 928-223-4823
  • Fax: 202-381-9567
Mailing address:
  • Phone: 928-223-4823
  • Fax: 202-381-9567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number58932
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number58932
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: