Healthcare Provider Details

I. General information

NPI: 1982223087
Provider Name (Legal Business Name): WADE GILLARD FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2020
Last Update Date: 08/15/2022
Certification Date: 08/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 NELSON RD STE 100
LAKE CHARLES LA
70605-4187
US

IV. Provider business mailing address

4201 NELSON RD STE 100
LAKE CHARLES LA
70605-4187
US

V. Phone/Fax

Practice location:
  • Phone: 337-310-2273
  • Fax: 337-310-4520
Mailing address:
  • Phone: 337-310-2273
  • Fax: 337-310-4520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number212171
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: