Healthcare Provider Details

I. General information

NPI: 1780807438
Provider Name (Legal Business Name): SHAWN ALAN WADE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 11/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 S 16TH ST
LINCOLN NE
68502-3704
US

IV. Provider business mailing address

2300 S 16TH ST
LINCOLN NE
68502-3704
US

V. Phone/Fax

Practice location:
  • Phone: 402-475-1011
  • Fax:
Mailing address:
  • Phone: 402-475-1011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number941108
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number25070
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number38264
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: