Healthcare Provider Details

I. General information

NPI: 1689146128
Provider Name (Legal Business Name): JONATHAN WADE APRN-CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2018
Last Update Date: 12/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W LEOTA ST
NORTH PLATTE NE
69101-6525
US

IV. Provider business mailing address

9005 LAKEVIEW DR
NORTH PLATTE NE
69101-9489
US

V. Phone/Fax

Practice location:
  • Phone: 308-568-8470
  • Fax:
Mailing address:
  • Phone: 208-351-5470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number101511
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: