Healthcare Provider Details

I. General information

NPI: 1205364916
Provider Name (Legal Business Name): JACQUELINE E WADE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2017
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 MOUNT AUBURN ST STE 407
CAMBRIDGE MA
02138-5665
US

IV. Provider business mailing address

330 MOUNT AUBURN ST PARSONS 2
CAMBRIDGE MA
02138-5597
US

V. Phone/Fax

Practice location:
  • Phone: 617-868-7456
  • Fax: 617-868-9243
Mailing address:
  • Phone: 617-868-7456
  • Fax: 617-868-9243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number286632
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number286632
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: