Healthcare Provider Details

I. General information

NPI: 1992295000
Provider Name (Legal Business Name): WADE REYNOLDS FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2018
Last Update Date: 04/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3061 E VALLEJO DR
GILBERT AZ
85298-9059
US

IV. Provider business mailing address

3317 S HIGLEY RD STE 114
GILBERT AZ
85297-5437
US

V. Phone/Fax

Practice location:
  • Phone: 480-248-4154
  • Fax:
Mailing address:
  • Phone: 480-248-4154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number225061
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberRN183469
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: