Healthcare Provider Details

I. General information

NPI: 1811769029
Provider Name (Legal Business Name): ERIN OLIVIA WADE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2023
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4727 SUNBEAM RD STE 101
JACKSONVILLE FL
32257-6188
US

IV. Provider business mailing address

PO BOX 13834
TALLAHASSEE FL
32317-3834
US

V. Phone/Fax

Practice location:
  • Phone: 904-512-1899
  • Fax: 904-770-7592
Mailing address:
  • Phone: 850-205-0615
  • Fax: 855-975-0615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9117608
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: