Healthcare Provider Details

I. General information

NPI: 1346243516
Provider Name (Legal Business Name): TERRY S WADE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 S GRAND MESA DR
CEDAREDGE CO
81413-3822
US

IV. Provider business mailing address

255 S GRAND MESA DR
CEDAREDGE CO
81413-3822
US

V. Phone/Fax

Practice location:
  • Phone: 970-856-4111
  • Fax: 970-856-4114
Mailing address:
  • Phone: 970-856-4111
  • Fax: 970-856-4114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number32008
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: