Healthcare Provider Details

I. General information

NPI: 1104827922
Provider Name (Legal Business Name): WADE ALDEN DICKINSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 03/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3152 N MILLBROOK AVE #SUITE B
FRESNO CA
93703-1459
US

IV. Provider business mailing address

3812 N 1ST ST
FRESNO CA
93726-4301
US

V. Phone/Fax

Practice location:
  • Phone: 559-244-0133
  • Fax: 559-244-0148
Mailing address:
  • Phone: 559-495-3120
  • Fax: 559-495-3134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberA62554
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: