Healthcare Provider Details

I. General information

NPI: 1518969377
Provider Name (Legal Business Name): MICHELLE PINTO WADE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 03/07/2023
Certification Date: 05/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10325 SAN JOSE BLVD
JACKSONVILLE FL
32257-6204
US

IV. Provider business mailing address

168 SHADOW RIDGE TRL
PONTE VEDRA FL
32081-0068
US

V. Phone/Fax

Practice location:
  • Phone: 904-717-1034
  • Fax:
Mailing address:
  • Phone: 215-219-8182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberPA9113264
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberMA051342
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA113264
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: