Healthcare Provider Details

I. General information

NPI: 1801282074
Provider Name (Legal Business Name): ANDREA WADE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2015
Last Update Date: 01/21/2020
Certification Date: 01/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 N MOUNTAIN VIEW AVE FAS
SAN BERNARDINO CA
92415-3115
US

IV. Provider business mailing address

1406 BAILEY AVE SUITE D
NEEDLES CA
92363-3115
US

V. Phone/Fax

Practice location:
  • Phone: 760-326-9230
  • Fax: 760-326-9355
Mailing address:
  • Phone: 760-326-9230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95002331
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: