Healthcare Provider Details

I. General information

NPI: 1962475558
Provider Name (Legal Business Name): WADE PEDIATRICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3505 W BROADWAY
MUSKOGEE OK
74401
US

IV. Provider business mailing address

3505 W BROADWAY
MUSKOGEE OK
74401
US

V. Phone/Fax

Practice location:
  • Phone: 918-683-8442
  • Fax: 918-683-8390
Mailing address:
  • Phone: 918-683-8442
  • Fax: 918-683-8390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number18036
License Number StateOK

VIII. Authorized Official

Name: KEVIN F WADE
Title or Position: OWNER
Credential:
Phone: 918-683-8442